o  LiBRAKUS  :; 


•♦i 


HEALTH 
SCIE  'GES 
LIBRARY 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/textbookofgynecoOOreed 


A  TEXT-BOOK   OF 

GYNECOLOGY/' 


EDITED    BY 

CHARLES   A.   L.  REED,  A.M.,  M.  D. 

President   of   the  American   Medical  Association   (1900-1901);   Gynecologist 

and  Clinical  Lecturer  on  Surgical  Diseases  of  Women  at  the  Cincinnati 

Hospital ;  Fellow  of  the  American  Association  of  Obstetricians  and 

Gynecologists  ;    Fellow   of   the    British    Gynecological   Society  ; 

Corresponding    Member    of    the    National    Academy   of 

Medicine  of  Peru,  etc. 


ILLUSTRATED   BY  R.  J.   HOPKINS 


NEW    YORK 

D.    APPLETON    AND    COMPANY 

1901 


Copyright,  1901 
By   D.   APPLETON   AND    COMPANY 


TO 

E.  C.  STOCKTON    REED,  M.  D.,  LL.  D. 

FORMER   PROFESSOR  OF  MATERIA  MEDICA  AND  THERAPEUTICS   IN  THE 
CINCINNATI  COLLEGE  OF  MEDICINE  AND  SURGERY 

THE    LABOR   OF    THE    EDITOR 

IN    THE    PREPARATION    OF    THIS   WORK 

IS    DEDICATED    AS    AN    EXPRESSION   OF    FILIAL    AFFECTION 


PREFACE 


In  the  iDreparation  of  this  work  there  has  been  held  in  view  the 
three  following  special  objects,  viz.: 

1.  The  formulation  of  a  Text-Booh  which  shall  serve  as  a  wording 
manual  for  'practitioners  and  students,  and  which  shall  embrace  the  best 
approved  developments  of  gynecology,  including  those  of  later  date 
than  are,  or  can  be,  included  in  a  work  of  similar  magnitude  by  a  single 
author. 

For  this  purpose  assignment  of  topics  was  made  to  a  considerable 
number  of  writers,  but  only  to  those  who  have  acquired  reputation  in 
connection  with  the  subjects  upon  which  they  Avere  asked  to  write. 
This  division  of  labour,  giving  to  each  writer  a  relatively  small  amount 
of  work,  insured  a  careful  preparation  of  copy  in  the  shortest  possible 
time,  and  the  issuance  of  a  strictly  up-to-date  volume. 

2.  The  co-operation  of  the  various  departments  of  medical  science 
in  their  synthetic  relation  to  gynecology. 

For  this  purpose  contributions  were  invited  from  several  writers 
who  are  not  gynecologists  in  the  strict  sense  of  the  term.  Thus  the 
various  topics  upon  pathology  were  given  to  pathologists,  while  those 
relating  to  bacteriology,  dermatology,  neurology,  hygiene,  etc.,  were 
assigned  with  similar  appropriateness.  As  a  consequence  a  single  chap- 
ter, in  some  instances,  is  based  upon  contributions  from  several  writers, 
while  the  whole  has  been  rendered  consecutive,  systematic,  and  homo- 
geneous by  the  Editor.  The  work  is  not,  therefore,  in  any  sense  a  mere 
aggregation  of  monographs. 

3.  The  specific  recognition  of  the  work  of  investigators  and  oper- 
ators in  gynecology  and  correlated  departments. 

For  this  purpose  invitations  to  contribute  to  the  work  were  limited 
to  those  who  had  already  contributed  something  to  science.  As  a  con- 
sequence Avriters  were  asked  to  treat  their  respective  topics  not  only  in 
a  general  way,  but  freely  to  express  their  individual  views  relative  to 
the  same. 

V 


yi  A   TEXT-BOOK  OF   GYNECOLOGY 

The  Editor  has  rendered  into  the  third  person  all  references  by  the 
different  writers  to  their  own  work.  In  this  way  and  by  reference  to 
the  table  of  contents,  the  reader  is  enabled  to  determine  the  authorship 
of  each  particular  j^aragraph. 

The  Editor  feels  a  special  sense  of  obligation  to  the  contributors  to 
the  volume,  whose  clear  and  lucid  comjDrehension  of  his  objects  and 
design  and  whose  scholarly  contributions  have  done  much  to  lessen 
his  task. 

The  work  of  illustration  has  been  in  the  hands  of  Mr.  E.  J.  Hop- 
kins, Avhose  previous  special  studies  in  anatomy  as  applied  to  art,  and 
whose  almost  intuitive  comprehension  of  the  task,  combined  with  ex- 
cellent technical  skill  on  his  part,  has  enabled  him  to  add  materially  to 
the  value  of  the  book. 

Dr.  Kenneth  W.  ]\Iillican,  Assistant  Editor  of  the  New  Yorh  Medi- 
cal Journal,  has  kindly  seen  the  pages  through  print,  and  it  is  to  his 
vigilance,  industry  and  scholarly  supervision,  that  the  Editor  is  in- 
debted for  the  elimination  of  errors,  Avhich  would  have,  otherwise, 
escaped  detection. 

To  Miss  Georgia  A.  H.  Tsaminger,  secretary  to  the  Editor,  acknowl- 
edgments are  due  for  efficient  service  in  transcribing  and  arranging 
manuscript. 

To  the  Publishers,  the  highest  praise  must  be  given  for  cordial 
co-operation  at  every  stage  of  the  work. 

Chaeles  a.  L.  Eeed,  Editor. 
Cincinnati,  Ohio. 


CONTRIBUTORS 


J.  W.  Ballantyne,  M.  D.,  F.  E.  C.  P.  E.,  F.  R  E. 

Lecturer  on  Midwifery  and  Gynecology,  School  of  the  Royal  Colleges.    Edin- 
burgh, Scotland. 

J.  H.  Carstens,  M.  D. 

Professor  of  Obstetrics  and  Clinical   Gynecology  in  the  Detroit  College  of 
Medicine,  Detroit,  Mich. 

Murdoch  Cameron,  A.  M.,  M.  D.,  F.  E.  C.  S. 

Regius   Professor   of   Midwifery   in   the   University    of   Glasgow.     Glasgow, 
Scotland. 

Henry  C.  Coe,  M.  D.,  M.  E.  C.  S. 

Professor   of   Gynecology   in   the   University    of   Bellevue   Medical    College. 
New  York,  N.  Y. 

John  G.  Clark,  M.  A..  M.  D. 

Professor    of    Gynecology    in    the    University    of    Pennsylvania.     Philadel- 
phia, Pa. 

F.  X.  Dercum,  a.  M.,  M.  D. 

Clinical  Professor  of  Diseases  of  the  Nervous  System  in  Jefferson  Medical 
College.     Philadelphia,  Pa. 

Walter  B.  Dorsett,  M.  D. 

Professor  of  Obstetrics  and  Clinical  Gynecology  in  the  Beaumont  Medical 
College.     St.  Louis,  Mo. 

L.  H.  Dunning,  M.  D. 

Professor   of  the   Diseases   of  Women   in   the   Medical   College   of   Indiana. 
Indianapolis,  Ind. 

Frank  P.  Foster,  M.  D.,  LL.  D. 

Editor  of  the  New  York  Medical  Journal.     New  Yoik,  N.  Y. 

Samuel  G.  Gant,  M.  D. 

Professor  of  Rectal  Surgery  in  the  New  York  Post-Graduate  Medical  School. 
New  York,  N.  Y. 

Hobart  Amory  Hare,  M.  A.,  M.  D. 

Professor  of  Therapeutics  in  Jefferson  Medical  College.     Pliiladelphia.  Pa. 

Malcolm  L.  Harris,  A.  M.,  M.  D. 

Professor  of  Surgery  in  the  Chicago  Polyclinic.     Chicago,  111. 

Maximilian  Herzog,  B.  S.,  M.  D. 

Professor  of  Pathology  in  the  Chicago  Polyclinic.     Cliicago,  111. 

E.  J.  Hopkins,  B.  S. 

Artist.    New  York,  N.  Y. 

Joseph  Tabor  Johnson,  A.  M.,  M.  D. 

Professor    of    Gynecology    and    Abdominal    Surgery    in    the    University    of 
Georgetown.     Washington,  D.  C. 

vii 


yiii  A  TEXT-BOOK  OF   GYNECOLOGY 

Wyatt  G.  Johnston,  M.  D.,  F.  R.  C.  S. 

Professor  of  Bacteriology  and  Pathology  in  McGill  College  and  University. 
Montreal,  Canada. 

Matthew  D.  Mann,  A.  M.,  M.  D. 

Professor  of  Gynecology  in  the  Medical  Department  of  the  University   of 
Buffalo.     Buffalo,  N.  Y. 

Thomas  Charles  Martin,  B.  S.,  M.  D. 

Professor  of  Pathology  and  Rectal  Diseases  in  the  College  of  Physicians  and 
Surgeons.     Cleveland,  Ohio. 

Lewis  S.  McMurtry,  M.  D.,  LL.  D. 

Professor  of  Gynecology  and  Abdominal  Surgery  in  the  Hospital  Medical 
College.     Louisville,  Kj. 

Dan  Million,  M.  D.,  LL.  D. 

Former  Professor  of  Materia  Medica  and  Therapeutics  in  the  Miami  Medical 
College  of  Cincinnati.     Hamilton,  Ohio. 

Henry  P.  Newman,  M.  A.,  M.  D. 

Professor  of  Gynecology  in  the  College  of  Physicians  and  Surgeons  of  Chi- 
cago.   Chicago,  111. 

William  Warren  Potter,  A.  M.,  M.  D. 

Secretary  of  the  American  Association  of  Obstetricians  and  Gynecologists, 
and  Editor  of  the  Buffalo  Medical  Journal.     Buffalo,  N.  Y. 

A.  Ravogli.  M.  D.,  LL.  D. 

Professor  of  Dermatology  in  the  University  of  Cincinnati.     Cincinnati,  Ohio. 

Charles  A.  L.  Reed,  A.  M.,  M.  D. 

Gynecologist  and  Clinical  Lecturer  on  Surgical  Diseases  of  Women  at  the 
Cincinnati  Hospital.    Cincinnati,  Ohio. 

Hunter  Robb.  A.  M.,  M.  D. 

Professor  of  Gynecology  in  the  Medical  Department  of  the  Western  Reserve 
University.     Cleveland,  Ohio. 

James  F.  W.  Ross,  M.  D.,  L.  R.  C.  P..  Eno:land. 

Lecturer   on   Clinical   Gynecology   in   the  University   of  Toronto.     Toronto, 
Canada. 

A.  W.  Mayo  Robson,  F.  R.  C  S. 

Professor  of  Surgery  in  the  Yorkshire  College  of  the  Victoria  University. 
Leeds,  England. 

J.  L.  ROTHROCK,  A.  M.,  M.  D. 

Instructor  in  Pathology  in  the  University  of  Minnesota.     St.  Paul,  Minn. 

W.  Japp  Sinclair,  M.  A.,  M.  D.,  F.  R.  C.  S. 

Professor  of   Obstetrics   and   Gynecology   in   Owen's   College,  Victoria   ITni- 
versity.     INIanchester,  England. 

Horace  J.  Whitacre,  B.  S.,  M.  D. 

Lecturer  on  Clinical  Surgery  and  Demonstrator  of  Pathology  in  the  Univer- 
sity of  Cincinnati.     Cincinnati,  Ohio. 

E.  Gustave  Zinke,  M.  D. 

Professor  of  Obstetrics  and  Clinical  Midwifery  in  the  University  of  Cincin- 
nati.   Cincinnati,  Ohio. 


CONTENTS 


CHAPTER    I 

PROLEGOMENA 

Gynecology  defined    ..... 

Historical   resume 

Gynecology  as  a  specialty        .         . 

Nomenclature  of  gynecology    . 

Eadicalism  and  conservatism  in  gynecology 


PAGE 

Reed 

1 

,, 

1 

,, 

2 

Foster- 

3 

Reed 

4 

Prevalence 

Causes         .... 

CiA'ilization    . 

Education 

Personal  habits     . 

Occupation    . 

Diseases 

Copulation    . 

Prevention  of  conception 

Criminal  abortion 

Childbirth      . 

The  social  evil 


CHAPTER    II 

GENERAL   ETIOLOGY   OF   DISEASES   OF   WOMEN 

.     Reed 


10 
10 
10 
10 


CHAPTER    III 

GENERAL  PATHOLOGY  OF  THE  FEMALE  GENERATIVE  ORGANS 

Local  pathology  conforms  to  general  pathologic  laws  .         .     Berzog 
Peculiarities  depending  upon  differentiated  functions 

IMenstruation 

Ovulation  in  its  relation  to  pathologic  states 

Gestation  in  its  relation  to  pathologic  states 

The  poise  of  the  uterus  and  its  variations     . 

Bacterial  origin  of  inflammatory  diseases  of  the  female  genitalia 

Tuberculosis        .... 

Syphilis       .         .         . 

Trophic  changes 

Neoplasms  .... 


1-2 
12 
12 
13 
13 
15 
1.5 
17 
17 
17 
18 


A   TEXT-BOOK   OF   GYNECOLOGY 


CHAPTER    IV 

GENERAL  THERAPEUTICS  OF  GYNECOLOGY 


General  medication 
Serum    therapy 
Local  medication 
Balneotherapy    . 
Suggestion 
Electricity 
Massage 


Reed 


PAGE 

20 
21 
22 
22 
23 
23 
24 


CHAPTER    V 

THE    GYNECOLOGICAL    ARMAMENTARIUM 

The  gynecological  armamentarium  .         .         ,         .         .         .     Robb 


27 


CHAPTER   VI 

DIAGNOSIS 

Definition  and  scope  .  

Indications  and  contraindications  for  vaginal  examination 

The  gynecologic  examination 

Physical  examination 

The   armamentarium 

The  examination  itself 

Inspection  of  the  external  genitals 

Digital  examination 

Bimanual  examination 

Rectal   exploration    . 

Examination  under   anaesthesia 

Auscultation,  percussion,  and  general  palpation  of  the  ab 

domen  .... 
Regions  of  the  abdomen  . 
Instrumental  examination 

(n)  The  speculum 

(/>)   The   sound      . 

{€)   The  dilator    . 

{(})   The  curette   . 

(p)   The   aspirator 
Examination  of  the  secretions — 

Urines,  faeces,  menstrual  fluid 
Examination   of  the  blood 
Examination  of  the  nervous  system 


Reed 

29 

„ 

30 

Potter    . 

30 

„ 

31 

55 

31 

55 

33 

55 

34 

55 

35 

55 

37 

55 

39 

,5                    . 

40 

5, 

40 

Reed 

41 

., 

42 

Potter    . 

42 

,, 

45 

55 

45 

„ 

46 

„ 

47 

Reed 

47 

55 

49 

49 

CHAPTER    VII 

SEPSIS 

Sepsis  defined  .... 

The  bacteria  of  sepsis 

Local    sepsis       ..... 

Symptoms,  pathology,   treatment 
General   sepsis 

Symptoms,  pathology,  treatment 


Reed 


50 
50 
55 
56 

57 
58 


CONTENTS 


CHAPTER    VIII 


ANTISEPSIS 


Antiseptic  provisions  of  Natur 

Sterilization 

Mechanical  means 
Heat      .... 
Germicidal  agents 

l^he  nurse 

The  room 

The  patient 

Instruments  and  dressings 

Sutures  and  ligatures 

Post-operative   antisepsis 

The  surgeon 

Hand   sterilization 

Gloves  .... 


Reed 


PAGE 
GO 

00 
Gl 
61 
63 
63 
64 
66 
66 
67 
68 
69 
69 
70 


Definition 
Pathology 
Causes 
Symptoms 

Diagnosis   . 

Treatment 

Prophylactic 
Restorative 


CHAPTER    IX 

SHOCK 


Reed 


12 
72 
72 
72 
73 
74 
74 
74 


CHAPTER    X 


HEMORRHAGE    AND    HEMOSTASTS 


Hemorrhage 

Symptoms 

Diagnosis 
Treatment  of  hemorr 
Hemostasis 

Styptics 

Heat 

Pressure 

Angiotripsy 

Electric  hemostasis 

Ligatures 


hage 


Reed 


Newman 
Reed 


78 
78 
79 
79 
79 
79 
80 
80 
81 
83 
86 


CHAPTER    XI 

ANAESTHESIA   AND    ANESTHETICS    IN    GYNECOLOGY 

Definition  Hare 

Anaesthetic   agents 

Race  and  temperament  in  the  selection  of  an  anaesthetic        .         „ 
Indications  and  contraindications  for  the  use  of  chloroform 

and   ether „ 


87 
87 
88 


A   TEXT-BOOK   OF   GYNECOLOGY 


Ether  in  its  relation  to  bodily  temperature 

Choice  of  anaesthetics  in  children 

Bromide  of  ethyl 

Ether  and  its  administration 

Mixed  vapours  and  their  administration 

Chloroform  and  its  administration 

Management  of  accident  in  anaesthesia 

Anaesthetic  mixtures 

Central  anaesthesia  by  cocaine 

General  anaesthesia  by  alcohol 

General  anaesthesia  by  hypnosis 

Local  anaesthesia 


Hare 


Reed 


PAGE 

89 
91 
91 
92 
93 
94 
95 
98 
97 
97 
98 
98 


CHAPTER   XII 

ABDOMINAL   SECTION 

Terminology 

Preliminary  treatment  of  the  patient 

The  evils  of  hypercatharsis 

Examination  of  the  urines 

Instruments 

Location  of  the  incision 

Dii-ection  and  varieties     . 

The  incision   itself     . 

Closure        .... 

Drainage     .... 


Reed 

99 

•5 

100 

,) 

101 

,, 

102 

Rohh 

103 

Reed 

103 

„ 

105 

„ 

107 

„ 

109 

jj 

114 

CHAPTER    XIII 

THE   EXTERNAL   ORGANS   OF   GENERATION   IN   WOMEN 

Definitions Reed        .  .117 

Development „           .  .     117 

Malformations  of — 

(ff)  Vulva Ballantyne  .     118 

(h)  Vagina .,  .126 

The  hymen Reed        .  .     131 

Malformations  of  the  hymen Ballantyne  .     131 


CHAPTER    XrV 

INJURIES    OF    THE    EXTERNAL    GENITAL    ORGANS 

Injuries  from — 

(a)  External  violence Dorsett 

(&)  Parturition     . 

(c)   Sexual  intercourse 

Pudendal  hematocele Reed 

Injuries  of  the  vagina 
Rupture 

Urinary  fistulse Ross 

Vesico-vaginal  fistulae 

Sims's  operation Reed 


135 
136 
136 
136 
139 
139 
139 
139 
144 


CONTENTS 


Vesico-vaginal  fistulae — 

Ross's  operation 

Reed's    operation 

After-treatment     . 
Utero-vaginal    fistulae 

Treatment 
Recto-vaginal   fistnlae 

Causes  . 

Operation   (Mayo  Robson's) 


Ra 


Mayo  RoJiHott 


PAGE 

145 
14() 
148 
151 
151 
152 
152 
153 


CHAPTER    XV 

INJURIES    OF    THE    EXTERNAL    GENITAL    ORGANS — {COflt  111116(1) 


Rape 

Objective   evidences 

Local    condition 

Injuries  on  other  parts 

Condition   of  clothing 
Schedule  for  examination 
Indecent  assault 
Prolapse      .... 
Injuries  of  perineum,  vagina 
Uterus         .... 


W.  Joh 

uson 

150 
150 
157 
158 
158 
159 
160 
161 
162 
162 

CHAPTER    XVI 

INFECTIONS    OF    THE    EXTERNAL    GENITAL    ORGANS 


Bacteriology  of  the  external  genital  organs 
Mixed  infections        .... 
Gonorrhoea  ..... 

Tuberculosis 

Erysipelas  ..... 

Erysipelas  and    puerperal   infection 
Diphtheria  ..... 

Aphthae       ...... 

Aerogenous  infection 

Bilharzia     ...... 

Chancroid 


Reed 


Wliitacre 
Reed 


Ravogli 


16.3 
105 
160 
171 
177 
178 
179 
179 
180 
180 
181 


CHAPTER    XVII 

DISEASES    OF    THE    SKIN    OF    THE    FEMALE    GENITALS 


Intertrigo   . 

Erythema   . 

Oedema 

Eczema 

Folliculitis 

Herpes  progenitalis 

Pruritus  vulvfe 

I'athology 

Causes 


Ravogli  . 

191 

„ 

194 

„ 

195 

)j 

190 

5» 

198 

)) 

200 

)) 

202 

Reed 

203 

l\(iro(/H  . 

204 

XVI 


A  TEXT-BOOK  OF  GYNECOLOGY 


Retro-displacements Reed 

Symptoms  and  diagnosis „ 

Treatment  ........... 

Massage .         .         .         „ 

Pessaries •        „ 

Surgical Mann 

Shortening  the  round  ligament;   Alexander's  operation; 

vaginal  operation;  fixation  operations  .         .         .         „ 

Anterior  abdominal  cuneohysterectomy     ....     Beed 
Anterior  displacements     ......... 

Prolapsus Herzog 

Inversion Reed 


CHAPTER    XXV 

PARTURIENT  INJURIES  AND  FOREIGN  BODIES  OF  THE  UTERUS 


Parturient   injuries    . 

Rupture  .         .         .         . 

Laceration  of  the  cervix     . 
Trachelorrhaphy 

Instruments 
Vesico-uterine    fistulae 

Reed's  operation 
Nonparturient  injuries 
Wounds  from  external  causes 
Foreign   bodies 


Reed 


RoI)l) 
Ross 
Reed 


CHAPTER   XXVI 

INFECTIONS    OF    THE    UTERUS 

The  uterus 

The  endometrium 

The  secretion  of  the  uterine  cavity 

The  myometrium 

Bacteria  of  the  uterus 

Infections   . 

Endometritis   and   metritis 

Pathology 

Causes 

Symptoms 

Diagnosis 

Treatment 
Topical 
Curettage 

Instruments 


McMiirtry 

Reed 

Sinclair 
Reed 


Rohh 


CHAPTER   XXVII     - 

INFECTIONS  OF  THE  UTERUS — (Continued) 
Specific — 

Gonococcous  infection Reed 

Streptococcous  infection „ 


372 
376 


CONTENTS 


xvii 


Specific — 

Tuberculosis  infection 
Sj'philitic  infection 
Echinocoecous  infection 


Whitoore 

Rffd 


PARE 

384 
391 
393 


CHAPTER    XXVni 

3fEOPLAiS31S    or    THE    rXJERtJS 


Neoplasms  of  the  utenis  in  general 
Benign   neoplasms 
Fibromyomata  . 

Causes,  pathology,  histoiy 

Seeondaiy  degenerations 

Diagnosis 
Complicating  pr^nancy 
Treatment 

Medicinal  and  electrical 

Surgical 

Indications   . 

Myomectomy 

Supravaginal  hysterectomy 

Panhysterectomy 

Eeed's  operation 

Vaginal  myomotomy 

Extirpation  of  polypi 


Herzog   . 

.     396 

.     390 

.     39G 

39fj_397 

,, 

.     399 

McMui-trij 

.     402 

.     403 

.     404 

.     404 

.     404 

Bo-^s 

.     405 

.     407 

.     410 

.     415 

Feed 

.     417 

Dunniiifj 

.     420 

,, 

.     424 

CHAPTEE    XXIX 
isEOPLASiis  OF   TiTE   T7TERTTS — {Continued) 


Malignant  neoplasms 
Syncytioma  malignum 

Pathology 

Histology 

Causes 

Symptoms 

Treatment 
Adenoma     . 

Symptoms 

Diagnosis 

Treatment 
Sarcoma 

Pathology 

Histology 

Symptoms 

Causes 

Treatment 
Carcinoma 

Pathology 

Histology 

Causes  . 

Symptoms 

Pregnancy  as 


a  complication 


Reed 

.     42G 

Herzog 

.     426 

.     427 

.     427 

Reed 

.     42S 

.     428 

.     429 

Rerzoy 

.     429 

Reed 

.     431 

.     431 

.     431 

Eerzofj 

.     432 

.     432 

.     433 

Reed 

.     435 

.     430 

.     436 

Berzofi    . 

.     437 

.     438 

.     439 

Reed 

.     440 

.     442 

■! 

.     443 

XVlll 


A   TEXT-BOOK  OF   GYNECOLOGY 


Carcinoma — 

Palliative  treatment     .         .         .         .         . 

Radical    treatment        .         .         .         .         . 

Vaginal   hysterectomy  .         .         .         . 

Instruments     ...... 

Abdomino-vaginal  panhysterectomy 
Extended   operation      .         .         .         .         . 

Byrne's  operation  of  electro -hysterectomy 
Results  of  hysterectomy      .         .         .         . 


PAGE 

Carstens 

444 

Reed 

447 

Newman 

447 

Robb 

448 

GarsteiiK 

453 

Reed 

453 

1} 

456 

;j 

458 

CHAPTER    XXX 

C.ESAREAX    SECTION    AND    ITS    MODIFICATIONS 

Definition  ..........     Cameron 

Historical  resmne       .   ,     . 
Preparations       .... 

Position  of  child  and  placenta 
The  operation     .... 

Sanger's    method 
Porro's   modifications 


460 
460 
465 
465 
466 
470 
471 


CHAPTER    XXXI 

MALFORMATIONS     AND     DISPLACEMENTS     OF    THE     FALLOPIAN     TUBES 

Absence  and  defective  development         .....     BalJanfijne     .  473 

Supernumerary  and  accessory  tubes       .....  „  .  474 

Accessory  ostia  .........  „  .  474 

Displacements     ..........  „  .  477 


CHAPTER    XXXII 


NEOPLASMS  OF  THE  FALLOPIAN  TUBES 


Benign  neoplasms      ..... 

.     Reed 

.     478 

Papillomata 

,, 

.     478 

Cystomata     ...... 

„ 

.     480 

Lipomata       ...... 

„ 

.     480 

Fibroniyomata 

„ 

.     481 

Malignant  neoplasms         .... 

„ 

.     481 

Carcinomata 

„ 

.     481 

Sarcomata 

„ 

.     482 

CHAPTER    XXXIII 

INFECTIONS    AND     INFLAMMATION     OF     THE    FALLOPIAN     TUBES 


Infections  in  general         ...... 

Bacteria  of  the  Fallopian  tubes  in  health   . 
Bacteria  of  the  Fallopian  tubes  in  disease 
Relations  of  infections  to  inflammation  of  the  tubes 
Catarrhal   salpingitis         ...... 

Morbid  histology  of  salpingitis       .... 

Acute 

Chronic  ........ 

Hydrosalpinx 


Reed 

483 

Sinclair 

484 

„ 

484 

Clark 

487 

» 

489 

489 

!> 

489 

H 

491 

„ 

495 

CONTENTS 


Hematosalpinx 

Pyosalpinx 

Symptoms  and  diagnosis  of  salpingitis 


Clark 


Rohh 


PAGE 

499 
499 
501 


CHAPTER    XXXIV 


INDIVIDUAL     INFECTIONS     OF     THE     FALLOPIAN     TUBES 

Infections  by — 

Gonoeoccus            

.     Reed 

512 

Streptococcus 

„ 

516 

Bacillus   tuberculosis   .... 

.    Whitacre 

519 

Bacillus  coli  communis 

.    Reed 

528 

Pneumococcus 

„ 

529 

Staphylococcus     

» 

530 

Saprophytes           

■ 

530 

Septic  vibrion 

„ 

531 

Actinomyces          ..... 

. 

531 

CHAPTER    XXXV 

TREATMENT    OF    INFECTIONS    OF    THE    FALLOPIAN     TUBES 


The  natural  course  and  termination  of  inflammatory 

eases  of  the  Fallopian  tubes 
Hygienic  treatment 
Medicinal  treatment 
Local  treatment 
Massage 
Electricity 
Drainage 

Vaginal   incision 

Inguinal  or  inguino-vaginal 

Abdominal  and  abdomino-vaginal 

Rectal  puncture    .... 

Aspiration 

Conservative  operations  on  the  tubes 
Radical  treatment     .... 

Salpingectomy       .... 

Tait's  operation    .... 

Modifications  of  Tait's  operation 

Abdominal  panhysterectomy 
Doyen's  operation      .... 

Modifications,  indications,  and  limitations 


dis- 


Clark 

532 

Coe 

535 

„ 

536 

,j 

537 

,, 

538 

Reed 

539 

,, 

540 

„ 

541 

542 

,, 

544 

„ 

546 

,, 

546 

Coe 

546 

Reed 

549 

,, 

549 

!J 

551 

!1 

553 

„ 

554 

556 

■) 

557 

CHAPTER   XXXVI 

MALFORMATIONS    AND    DISPLACEMENTS    OF    THE     OVARIES 

Malformations Ballautync 

Absence 

Rudimentary   development 

Accessory  ovaries 

Coexistence  of  ovaries  and  testicles 


560 
560 
560 
561 
562 


XX 


A  TEXT-BOOK  OF   GYNECOLOGY 


Displacements  of  the  ovary Reed 

Decensus  and  prolapsus    . „ 

Hernia 


PA6B 

563 
563 
564 


CHAPTER    XXXVII 

INFECTIONS   AND   INFLAMMATIONS   OF   THE   OVARIES 

Classification      ......... 

Hyperfemia         . 

Acute  inflammation  ....... 

Chronic  inflammation        ....... 

Bacteria  of  the  ovaries 

Individual   infections 

Streptococcous  infection Reed 

Gonococcous  infection         ...... 

Pneumococcous   infection     ...... 

Bacillus  coli  communis  infections       .... 

Tubercular  infections  ....... 


Whitacre 

567 

Reed 

567 

„ 

568 

Whitacre 

569 

Sinclair 

570 

„ 

571 

Reed 

571 

„ 

574 

„ 

574 

„ 

575 

Whitacre 

575 

CHAPTER    XXXVIII 


TREATMENT    OF    INFECTIONS    OF    THE    OVARIES 


Preliminary   consideration 
Natural  terminations 
Palliative  treatment 
Conservative   treatment 
Radical  treatment 

Oophorectomy 
Unilateral 

Effects :   primary,   secondary 


Reed 

579 
579 
581 

582 
584 

J.  T.  Joh 

nson. 

584 

Reed 

585 
586 

CHAPTER    XXXIX 

TROPHIC    DISEASES    OF    THE    OVARIES 

Atrophy Coe  .         .     592 

Cirrhosis Whitacre         .     593 

Hypertrophy Coe  .         .     594 


CHAPTER    XL 

NEOPLASMS   OF   THE   OVARIES 

Small  benign  cysts    ........ 

Follicular  cysts 

Cysts  of  the  corpus  luteum 

Tubo-ovarian  cysts 

Neoplastic   cysts 

Proliferation   cysts 

Dermoid  cysts 

Solid  tumours    ......... 

Fibroids  .         .         

Calcified  tumours 

Hematoma  ......... 


Rothrock 

.     597 

„ 

.     598 

, 

:     599 

, 

.     601 

, 

.     602 

, 

.     602 

, 

.     611 

.     614 

, 

.     614 

Reed 

.     615 

Coe 

.     618 

CONTENTS 


XXI 


Malignant  neoplasms Rothroch 

Carcinoma      .....■••••  »         ■ 

Sarcoma »>         • 

Endothelioma        . »         ■ 


PAGE 

619 
619 
622 
624 


CHAPTER    XLI 
NEOPLASMS  OF  THE  OVARIES — {Continued) 


Complications    .         .         .         . 
Symptomatology 

Diagnosis 

Treatment 

Ovariotomy         .         .         .         . 

History  .         .         .         . 

Indications    .         .         .         . 

Technique      .         .         .         . 

After-treatment     . 
Incomplete  ovariotomy     . 
Ovariotomy  during  pregnancy 


Reed 


J.  T.  Johnson 


Reed 


CHAPTER    XLII 


ECTOPIC    PREGNANCY 

Historical  resume McMurtri/ 

Definition Hersog 

Etiology " 

Classification » 

Course  and  termination v 

Histology " 

Symptomatology McMurtr 

Diagnosis ■  >' 

Treatment  .....•■■••  " 


627 
632 
633 
637 
638 
638 
639 
639 
645 
646 
647 


649 
650 
650 
652 
654 
656 
660 
662 
664 


CHAPTER    XLIII 

NEOPLASMS    OF    THE    BROAD    LIGAMENT 


The  bi-oad  ligament  . 
Varieties  of  neoplasms 
Cysts   (parovarian)    . 

Origin    . 

History 


Causes 


Symptoms,  complications,  diagnosis 

Treatment     ..... 
Hall -Hawkins  operation   . 
Hydiocele  of  the  long  ligament 
Fibroma  and  myoma 

Symptoms,  diagnosis,  treatment 

Dermoids 

Solid  tumours  of  the  round  ligiuiient 

pelvic  VMiicocclc,  iineuiisMial   varix,  i)liIeV)olithiasis 

f ';i  rciiioiiia,  sarcoma  ...... 


Reed 

669 

Zinke 

669 

„ 

670 

„ 

671 

)' 

671 

ji 

674 

V 

674 

„ 

675 

Reed 

676 

677 

Zinke 

677 

,, 

679 

Reed 

681 

,, 

681 

Zinke 

.  682 

.  686 

A    TEXT-BOOK  OF   GYNECOLOGY 


CHAPTER    XLIV 

INFECTIONS  OF  THE  BEOAD  LIGAMENT  AND  OF  THE  PELVIC  PERITONEUM 

Infections  of  the  broad  ligament      ......  Beed 

Pyogenic „ 

Pelvic  abscess — treatment „ 

Syphilitic  infection .         .         .         „ 

Tuberculous  infection .  Whitacre 

Tubercular  peritonitis „ 

CHAPTER    XLV 

MENSTRUATION 

Normal  menstruation        . 

Time  of  appearance 

Menstrual   cycle         ........ 

Quantity  of  discharge 

Character  of  discharge      ....... 

The  inducing  cause  of  menstruation       .... 

The  role  of  the  uterus       ....... 

The  role  of  the  Fallopian  tubes 

The  role  of  the  ovaries     ....... 

The  hygiene  of  menstruation  ...... 


PAGE 

688 
688 
689 
690 
691 
692 


MiUikin 

.  699 

„ 

.  701 

„ 

.  704 

,, 

.  704 

„ 

.  705 

!> 

.  706 

,, 

.  708 

„ 

.  709 

„ 

.  709 

,, 

.  712 

CHAPTER   XLVI 

THE    DISORDERS    OF    MENSTRUATION 

Menorrhagia 

General  systemic  causes       ...... 

Local  causative  diseases  above  the  pelvis  . 

Pelvic  causes        ........ 

Treatment 

Metrorrhagia      ......... 

Amenorrhoea       ......... 

Treatment 

Retention  of  the  menses  ....... 

Dysmenorrhoea  ........ 

Intermenstrual  pain  ....... 

Vicarious  menstruation 

The  menopause  ...  .... 


MiUikin 

.  714 

„ 

.  714 

„ 

.  714 

„ 

.  715 

.  716 

„ 

.  719 

„ 

.  720 

.  721 

„ 

.  723 

„ 

.  725 

.  734 

.  735 

.  738 

CHAPTER    XLVII 

THE    FEMALE    URINARY    APPARATUS 

Physical  examination Harris 

Catheterization  of  the  ureters „ 

Pawlik-Kelly  method „ 

LTse  of  the  uretercystoscope „ 

Harris's  urine  segregator           . „ 

Anomalies  of  the  kidneys „ 

Number „ 

Location „ 

Form 


744 
746 
746 
747 
747 
749 
749 
750 
751 


CONTENTS 


XXlll 


Movable  kidnoy 

Etiology 

Pathologic   anatomy 

Symptomatology 

Treatment 
Anomalies  of  the  ureters 
Strictures  of  the  ureters 
Nephrocytosis     . 
Nephrydrosis 

Pathologic  changes 

Symptomatology 

Diagnosis 

Treatment 


Harris 


PAGE 

752 
753 
755 

757 
759 
760 
760 
762 
702 
763 
765 
765 
766 


CHAPTER    XLVIII 


THE  FEMALE  URiNAKY  APPARATUS — {Continued) 


Renal  infections 

Symptomatology  and  diagnosis 

Treatment 

Tuberculosis  of  the  kidneys 

Pathologic    changes 

Symptoms  and  diagnosis 

Treatment 
Renal   calculi 

Pathology 

Symptoms  and  diagnosis 

Prognosis 

Treatment 
Tumours  of  the  kidney     . 

Pathology      .         .         . 

Symptoms  and  diagnosis 

Treatment 
Operations  on  the  kidneys 

Nephropexy 

Nephrotomy 

Nephrectomy 


Harris 


770 


I  Id 
774 
775 

776 
778 
778 
778 
780 
780 
781 
785 
787 
787 
788 
788 
789 


CHAPTER    XLIX 

THE    FEMALE    tJRINART    APPARATUS — {ConUn 


Cystitis        ..... 

Etiology         .... 

Bacteriology 

Pathologic   changes 

Symptoiuatology  and  diagnosis 

Treatment  .... 
Hyperfjfjnia  .... 

Tj'eatment  .... 
Foreign  bodies  in  the  Ijladdcr  . 

Treatment      .... 


lied) 
Harris 


790 
790 
791 
792 
793 
794 
795 
796 
796 
798 


XXIV 


A  TEXT-BOOK   OF  GYNECOLOGY 


Tumours  of  the  bladder Harris 

Symptomatology  and  diagnosis „ 

Treatment      . ,, 

Urethral   caruncle      ........... 

Treatment      . ,, 

Carcinoma  of  the  urethra „ 

Treatment      ........... 

Sarcoma  of  the  urethra .         .         „ 

Diverticula  of  the  urethra         ........ 

Treatment .         „ 

Stricture  of  the  urethra  . ■         „ 

Prolapse  of  tlie  urethra   . „ 

Treatment      ........... 

Foreign  bodies  in  the  urethra  ........ 

Dilatation  of  the  urethra         ........ 

The  urachus Reed 

Vesico-umbilical   fistula ,, 

Treatment „ 

Cysts  of  the  urachus  .......... 


CHAPTER    L 

THE    RECTUM 
Malformations   ...... 

Examination       ...... 

Displacements     ...... 

General  etiology  of  rectal  diseases 
Relation  to  intra-pelvic  disease  in  women 


Reed 

Martin 

Reed 

Gant 

Martin 


CHAPTER    LI 

INFECTIOIS'S    OF    THE    RECTUM 

Inflammation      .         .         .         .         .         .         .         .         .         .  Gant 

Periproctitis        ..........  „ 

Gonorrhoea Reed 

Syphilis Gant 

Tuberculosis        ............ 

Surgical  conditions  resulting  from  infections          .         .         .  „ 

Anal  ulcer  or  fissure Martin 

Ulceration  of  the  rectum „ 

Fistulse „ 

Stricture Gant 


CHAPTER   LII 

MEOPLASMS    OF    THE    RECTUM 

Adenoma Gant 

Lipoma ■         „ 

Fibroma „ 

Papilloma „ 

Angioma      ............ 

Terratoma 


CONTENTS 


XXV 


Retention  cysts 
Myoma        .         .         .         . 
Enchondroma 
Malignant  growths   . 

Operations     . 

Divulsion 

Proctotomy  . 

Curettage 

Colostomy     . 

Excision 
Hemorrhoids 

Injection 

Whitehead's  operation 

Ligature 

Clamp-and-cautery 


Gant 


PAGE 

844 
844 
844 
844 
846 
840 
846 
846 
846 
847 
848 
851 
852 
852 
853 


CHAPTER    LIII 

PELVIC    DISEASES    AND    NERVOUS    AFFECTIONS 

Neurasthenia Dercuni  .  .  856 

Symptoms „  .  .  856 

Conclusion „  .  .  860 

Hysteria „  .  .  860 

Symptoms     ..........  „  .  .  860 

Pathology „  .  .  862 

Conclusions  . „  .  .  864 

Operations  for  the  neuroses „  .  .  864 

Nervous  symptoms  of  pelvic  disorders  .....  „  .  .  865 


A  TEXT-BOOK   OF   GYNECOLOGY 


CHAPTER    I 

PROLEGOMENA 

-Gynecology — Historical    resume — Gynecology    as    a    specialty — Nomenclature    of 
gynecology — Radicalism  and  conservatism  of  gynecology. 

Gynecology. — This  word  (derived  from  ywrj,  a  woman,  and  X6yo% 
understanding)  implies,  etymologically,  the  study  or  understanding  of 
woman;  but  in  its  applied,  modern  sense,  it  means  a  consideration  of 
the  names,  causes,  prevention,  symptoms,  diagnosis,  pathology,  and 
treatment,  of  diseases  peculiar  to  women. 

Historical  Resume. — The  evidence  revealed  by  numerous  papyri 
•establishes  beyond  doubt  that  the  ancient  Egyptian  physicians  under- 
stood somewhat  of  the  diseases  of  women,  and  that  there  were  practi- 
tioners who  devoted  themselves  especially  to  their  treatment.  The 
Mosaic  writings  reveal  keen  intelligence  of  the  menstrual  and  repro- 
ductive functions;  and  the  Talmud  records  the  operation  which  subse- 
quently became  known  as  the  Cesarean.  The  Greeks,  deriving  their 
knowledge  from  the  Egyptians,  improved  upon  their  inheritance,  and, 
with  the  writings  of  Hippocrates,  marked  the  beginning  of  gynecology 
in  the  sense  of  a  systematic  treatise  on  the  diseases  of  women.  Inflam- 
mations, the  disorders  of  inenstruation,  and  uterine  displacements,  here 
occur  for  the  first  time  in  recorded  science.  The  writers  of  the  next 
five  hundred  years  simply  elaborated  upon  the  teachings  of  the  great 
master.  The  speculum  vaginae  and  the  speculum  ani  were  described  by 
•Galen,  while  vaginal  examinations  by  the  digital  method  were  practised 
long  before  that  epoch.  In  the  third  century  b.  c,  Soranus  wrote  a  book 
on  the  uterus  and  pudendum.  Aetius,  Paul  of  iEgina,  and  other 
writers,  show  active  and  intelligent  attention  to  divers  diseases  of 
women,  including  sterility.  The  speculum,  duck-bill  and  multivalvu- 
lar, was  in  use,  as  were  the  uterine  sound  and  uterine  dilators.  These 
instruments,  and  a  knowledge  of  their  use,  however,  seem  to  have 
dropped  into  oblivion  during  the  long  night  of  the  Middle  Ages.  It  was 
not  until  1761  that  Astruc,  of  the  medical  faculty  of  Paris,  reinvented 
the  speculum  which  he  describes  in  his  writing,  but  which  passed  with- 
<^ut  attracting  the  general  attention  of  the  profession.  la  1801  Reca- 
2  1 


2  A   TEXT-BOOK  OF   GYNECOLOGY 

mier  introduced  his  really  practicable  instrument  by  that  name,  an 
event  which  marked  the  revival  of  the  long-lost  gynecologic  art.  From 
this  date  progress  has  been  rapid.  In  1809  Ephraim  McDowell,  of 
Kentucky,  did  the  first  ovariotomy,  an  event  which  marked  the  begin- 
ning of  intrapelvic  gynecologic  surgery. 

Uterine  depletion  hy  leeches  (Guilbert);  the  iise  of  the  uterine 
sound  (Lair);  topical  intrauterine  and  intravaginal  treatment  (Melier); 
the  curette  (Eecamier);  uterine  pathology  (Simpson);  inflammation  of 
the  uterus  (Bennet);  anaesthesia  (Wells-Simpson);  the  rediscovery  of 
the  univalve  speculum  (Sims);  operation  for  vesico-vaginal  fistulge 
(Sims);  oophorectomy  (Battey);  pathology  and  operative  treatment  of 
the  Fallopian  tubes  (Tait);  infection  of  the  upper  genitalia  (ISToeg- 
gerath);  perineorrhaphy  (Emmet);  antisepsis  (Lister);  and  hemostasia 
(Koeberle),  are  among  the  more  striking  events  which  have  character- 
ized the  evolution  of  modern  svirgical  gynecology.  During  this  period 
it  has  been  a  constant  beneficiary  of  the  general  development  in  the 
medical  sciences.  ]\Iany  other  names  are  entitled  to  be  recorded  upon  a 
scroll  more  complete  than  is  consistent  with  the  limitations  of  this 
work.  The  aggregate  result  of  such  developments  as  are  herein  indi- 
cated comprises  what  is  known  as  modern  gynecology.  It  is  obvious  at 
a  glance  that  the  great  steps  that  have  been  taken  in  the  development 
of  this  department  of  medical  science  have  been  almost  exclusively  sur- 
gical; and  with  them,  more  conspicuously  than  any  other  names,  must 
stand  associated  those  of  Marion  Sims,  Lister,  and  Lawson  Tait.  It 
must  be  admitted  that  the  tendency  to  exclude  rational  therapy,  in 
its  broader  and  more  general  as  well  as  in  its  local  and  special  sense, 
from  consideration  in  connection  with  the  treatment  of  diseases  pecul- 
iar to  women,  is  an  evil.  The  fact  should  be  held  in  constant  view, 
that  gynecology  is  an  integral  and  thoroughly  correlated  department 
of  medical  science.  The  gynecologist  should,  therefore,  be  grounded, 
not  alone  theoretically,  but  by  years  of  actual  practice,  in  all  that  per- 
tains to  the  most  advanced  state  of  the  healing  art,  considered  in  its 
broadest  sense.  He  should,  moreover,  keep  himself  in  constant  touch 
with  medical  science  in  the  various  phases  of  its  evolution. 

Gynecology  as  a  Specialty. — It  is  a  fundamental  law  that  progress 
is  due  to  the  gradual  evolution  of  heterogeneity.  This  process  is  exem- 
plified, not  alone  in  the  various  phases  of  organic  life,  but  in  complex 
social  organisms.  The  medical  profession,  considered  as  a  constituent 
element  of  the  social  fabric,  is  subservient  to  the  same  law.  Special 
aptitudes  and  special  knowledge  lead  to  correspondingly  special  occu- 
pations. This  comes  as  a  result,  not  alone  of  the  tastes  and  predilec- 
tions of  the  individual,  but  of  the  discrimination  of  those  who  become 
his  patrons.  It  follows,  therefore,  that  those  who  would  assume  to 
be  specialists  in  any  department  of  medical  practice,  but  who  are  un- 
qualified for  the  responsibilities  which  they  invoke,  sooner  or  later 
must  fail.  Specialism  in  medicine  has  an  ethical  basis  which  can 
not  be  ignored.    These  facts  render  the  segregation  of  medical  science 


PROLEGOMENA  3 

in  its  practical  application  inevitable.  There  is  no  practitioner  but 
knows  and  does  some  things  better  than  he  knows  and  does  others,  and 
he  is  to  that  extent  a  specialist.  If,  however,  he  were  to  concentrate 
his  attention  exclusively  upon  those  things  which  he  knows  best  and 
to  ignore  those  things  of  which  he  knows  least,  his  intelligence  would 
move  only  upon  convergent  lines.  This  is  indeed  the  inlierent  mis- 
chievous tendency  of  specialism,  and  one  which  the  gynecologist,  as 
other  specialists,  should  never  cease  to  resist.  The  sphere  of  the  gyne- 
cologist's labours  has  already  resulted  in  a  broadening  of  his  activ- 
ities. His  constant  experience  with  intraperitoneal  conditions  has 
resulted  in  his  expansion  into  an  abdominal  surgeon,  a  fact  recog- 
nised, not  alone  by  the  general  consensus  of  the  profession,  but,  spe- 
cifically, by  the  creation  in  medical  schools  of  professorships  of  "  gyne- 
cology and  abdominal  surgery,"  or  of  "  abdominal  and  pelvic  surgery." 
Nomenclature  of  Gynecology. — One  of  the  chief  embarrassments 
in  the  evolution  of  a  science  is  an  indetermined  and  essentially  de- 
fective terminology.  Words  are  but  symbols,  and  each  word,  to  prop- 
erly fulfil  its  office,  should  be  easily  and  definitely  translatable  in  the 
mind  into  that  for  which  it  stands.  In  this  way  alone  can  language 
subserve,  in  the  highest  degree,  its  legitimate  function  as  a  medium  for 
conveying  ideas  from  one  person  to  another.  The  language  of  medi- 
cine, says  Dr.  Frank  P.  Foster,  is  by  no  means  free  from  the  defective 
neologisms  that  are  to  be  found  in  the  contemporary  literature  of  the 
other  sciences.  That  they  are  more  abundant  in  the  writings  of  gyne- 
cologists than  in  other  medical  writings  he  is  not  prepared  to  admit. 
He  considers  that  their  formation  is  for  the  most  part  to  be  attributed 
to  the  rage  for  designating  diseases,  operations,  and  the  like,  by  single 
words.  Their  defects  generally  consist  (a)  in  joining  a  Latin  word  to 
a  Greek  word  to  make  a  compound;  (&)  in  adding  a  G-reek  termina- 
tion to  a  Latin  word;  (c)  in  reversing  the  proper  order  of  the  terms 
of  a  compound;  or  (d)  in  retaining  an  aspirate  which  any  classical 
Greek  writer  would  have  suppressed.  The  following  are  examples 
of  these  forms  of  error:  (a)  "  rectocolporrhaphy,"  made  up  of  one 
Latin  and  two  Greek  words;  (h)  "  annexitis,"  borrowed  from  the  annex- 
ite  of  the  French;  (c)  "  hydronephrosis,"  instead  of  "  nephydrosis  "  ;  (d) 
"  anhydrous "  for  "  anydrous."  Most  of  these  defectively  formed 
words  have,  however,  established  themselves  firmly  in  the  favour  of  the 
multitude,  and  it  would  be  foolish  to  seek  to  root  them  out  at  this  late 
day;  nevertheless,  by  pointing  out  their  deficiencies  one  may  hope  to 
moderate,  in  some  degree,  the  further  coining  of  objectionable  terms. 
Far  more  to  be  regretted  than  these  errors  of  coinage,  is  the  perverted 
meaning  often  attached  to  well-known  words,  as  when  we  say  "  differ- 
entiate "  for  "  distinguish,"  or  speak  of  "  single  "  and  "  double  castra- 
tion ";  but  even  such  perversions,  however  much  they  may  offend  the 
fastidious,  throw  no  real  obstacle  in  the  student's  way.  The  same  can 
not  be  said,  however,  of  the  fancy  that  some  authors  have  shown  for 
dividing  retroversion  of  the  uterus,  for  example,  into  arbitrary  "  de- 


4  A  TEXT-BOOK  OP  GYNECOLOGY 

grees."  The  need  of  the  day,  long  since  emphasized  by  Jonathan 
Hutchinson,  is  for  the  legitimate  employment  of  well-understood 
words,  preferably  those  that  are  short,  easily  remembered,  and  so  far 
as  possible  in  the  vernacular. 

Radicalism  and  Conservatism  in  Gynecology. — The  essentially  sur- 
gical character  of  modern  development  in  gynecology  has  led  to  some 
abuses  that  are  the  necessary  incidents  of  all  surgical  evolution.  The 
operations  of  tenotomy  in  orthopa3dics,  of  tonsilotomy,  and  of  the  divi- 
sion of  the  recti  muscles  for  the  cure  of  strabismus,  were  followed  imme- 
diately after  their  introduction,  respectively,  by  indiscriminate  applica- 
tion that  resulted  in  damage  to  many  patients.  Other  examples  could 
be  cited.  In  gynecology  each  new  advance  has  been  characterized  by 
similar  experiences.  The  use  of  the  sound,  of  pessaries,  and  of  caustics, 
was  in  each  instance  attended  with  early  abuses.  Emmet's  operation 
for  the  repair  of  the  lacerated  cervix  was  followed  by  its  needless  per- 
formance in  many  cases.  Oophorectomy  and  the  more  comprehensive 
operations  upon  the  uterine  adnexa  were  followed,  immediately  after 
their  introduction,  by  efforts  to  relieve  by  their  means  conditions  to 
which,  in  the  light  of  subsequent  experience,  they  were  not  adapted. 
These  abuses,  if  such  they  can  be  designated,  are  to  be  construed  rather 
as  evidences  of  conscientious  efforts  on  the  part  of  the  profession  to 
determine  the  remedial  value  of  surgical  expedients.  Reactionary  in- 
fluences can  be  relied  upon  to  correct  these  tendencies.  The  actuating 
motive  in  gynecology,  as  in  other  departments  of  medical  and  surgical 
practice,  is  to  preserve  in  a  safe  or  entire  state,  or  to  protect  from  unne- 
cessary loss,  waste,  or  injury,  the  various  organs  or  structures  that  are 
the  seat  of  disease.  Any  departure  from  this  criterion  must  be  attended 
with  danger.  From  this  point  of  view,  conservatism  in  gynecology  is 
to  be  commended.  It  should  be  remembered,  however,  that  even  reac- 
tionary tendencies  may  go  to  dangerous  extremes.  This  is  sometimes 
exemplified  in  an  effort  to  conserve  an  organ  at  the  expense  of  the 
general  health  of  the  patient.  On  this  point  it  is  well  to  be  governed 
by  the  rule  tersely  enunciated  by  S.  C.  Gordon  {Philadelphia  Medical 
Journal,  August  19,  1899)  that  "  conservative  gynecology  demands 
saving  health  rather  than  diseased  and  useless  organs." 

All  the  splendid  achievements  of  modern  surgery,  however,  have 
been  made  in  violation  of  the  other  equally  legitimate  definition  of 
"  conservatism  " — namely:  "  Disposed  to  retain  and  maintain  what  is 
established,  as  institutions,  customs,  and  the  like;  opposed  to  innova- 
tion and  change;  in  an  extreme  and  unfavourable  sense  opposed  to 
progress."  In  view  of  the  fact  that  the  term  conservatism  of  neces- 
sity carries  with  it  the  meaning  expressed  in  the  last  as  well  as  in  the 
first  definition,  its  introduction  into  the  literature  of  gynecology  is  to 
be  considered  unfortunate.  The  life-saving  impulse  of  the  medical 
profession,  and  the  yet  unrelieved  necessities  of  afflicted  humanity, 
join  in  a  demand  for  every  innovation  that  will  increase  the  efficiency 
of  the  healing  art. 


CHAPTER    II 
GENERAL  ETIOLOGY  OF  DISEASES  OF  WOMEN 

Prevalence — Causes:  Civilization;  education;  personal  habits;  occupation;  dis- 
eases; copulation;  prevention  of  conception;  criminal  abortion;  childbirth; 
the  social  evil. 

Theee  is  a  prevailing  impression  that  the  diseases  peculiar  to 
women  are  increasing  relatively  to  the  population.  There  exist  no  data 
upon  which  such  an  affirmation  can  be  based.  The  impression  probably 
depends  for  its  existence  upon  the  fact  that  such  diseases  are  now 
better  understood  and  more  generally  treated  than  formerly.  Evidence 
is  not  wanting  to  indicate  that  the  Anglo-Saxon  woman  is  not  degen- 
erating. Bowditch  has  made  some  interesting  observations  on  the 
physique  of  women,  as  follows:  Of  over  1,100,  he  found  that  the  average 
height  was  158.76  centimetres  (5  feet  3^  inches).  Sargent,  in  nearly 
1,900  observations,  the  ages  of  the  women  ranging  from  sixteen  to 
twent\^-six,  found  the  average  slightly  higher.  Galton,  in  770  measure- 
ments of  English  women  from  twenty-three  to  fifty-one  years  of  age, 
also  found  a  higher  average — a  difference  due  in  part,  no  doubt,  to  the 
younger  age  of  a  number  of  the  American  subjects.  In  1,105  subjects 
in  ordinary  indoor  clothing  Bowditch  found  the  average  weight  to  be 
56.56  kilogrammes  (125  pounds).  These  observations,  compared  with 
276  by  G-alton,  show  that  the  average  weight  is  a  little  greater  among 
Americans,  It  would  seem  that  while  the  tallest  English  women  sur- 
passed the  tallest  American  women  in  height,  the  heaviest  American 
women  exceeded  the  heaviest  English  women  in  weight.  Specific  ob- 
servation of  this  systematic  character,  however,  is  not  necessary  to  im- 
press the  intelligent  traveller  with  the  generally  satisfactory  physique 
of  the  women  of  England  and  America.  It  is  true  that  many  defective 
specimens  are  found,  and  these  come  with  relatively  greater  proportion 
under  the  observation  of  the  physician.  But  no  one  can  fail  to  be 
impressed  with  the  fact  that  they  comprise  a  distinct  minority  of  the 
masses.  The  improvement  in  the  physique  of  women  has  been  very 
noticeable  since  the  sentiment  for  athletics  has  supplanted  that  for  the 
cloister,  and  since  outdoor  exercises  have  taken  the  place  of  those  seden- 
tary habits  which,  but  a  few  decades  ago,  were  considered  the  proper 
affectations  of  refinement.  With  that  other  and  vastly  larger  class  of 
people,  who  are  not  at  liberty  to  choose  their  occupations,  there  has 
been  a  distinct  inipr'ovcMncnt  in  pliysical  estate.    Improved  habitations, 


0  A  TEXT-BOOK   OF   GYNECOLOGY 

better  hygiene,  more  humane  regulation  of  occupation,  more  rational 
methods  of  education,  and,  with  all,  a  more  general  diffusion  of  pros- 
perity, are  responsible  for  this  improvement.  It  is  a  source  of  regret 
that  this  more  or  less  optimistic  view  must  be  tempered  by  a  frank 
recognition  of  yet  existing  evils  which,  to  a  certain  extent,  retard  the 
progressive  improvement  of  womankind,  and  are  largely  responsible  for 
the  diseases  which,  in  the  aggregate,  comprise  the  subject  of  this 
volume. 

Civilization. — The  assumption  has  been  made,  and  in  some  quarters 
entertained,  that  civilization,  in  the  aggregate,  exercises  a  deteriorating 
influence  upon  woman;  that  it  develops  her  mind  and  brain  and  nervous 
system  at  the  expense  of  other  elements  of  her  physical  organism. 
There  is  no  doubt  that  between  the  women  of  aboriginal  peoples  and 
those  who  belong  to  the  civilized  races  there  are  certain  physical  dif- 
ferences, some  of  which  tend  to  the  production  of  sexual  diseases  in 
the  latter.  The  reproductive  function  can  be  taken  as  an  index.  Sav- 
age women,  as  a  rule,  have  but  little  difficulty  in  childbed,  because  they 
have  large  pelves  and  bear  children  with  small  heads.  Accidents  in 
childbirth,  however,  do  occur  among  these  primitive  peoples  with  gen- 
erally fatal  results.  Currier  (Medical  Neivs,  1891),  who  has  studied  the 
physical  and  sexual  condition  of  the  North  American  Indians,  says: 
"  that  pelvic  disease  has  not  been  treated  among  Indians  does  not  prove 
that  it  does  not  exist."  The  fact  that  Indian  women  are  very  generally 
the  victims  of  venereal  diseases  establishes  upon  a  firm  basis  the  pre- 
sumption that  they  must  suffer  from  the  remoter  physical  consequences 
of  those  diseases.  Menstrual  habits' among  many  of  the  Indian  tribes 
may  well  serve  as  an  example  to  civilized  women.  The  Mosaic  rule  that 
women  during  this  period  shall  be  put  apart  for  seven  days  is  observed 
in  practice  by  these  lowly  people,  who  never  heard  of  the  records  of 
Leviticus.  JSTapheys,  confirmed  by  Holder  {American  Journal  of  Ob- 
stetrics, 1892),  says  that  "  it  is  an  inviolable  rule  among  all  these  tribes 
for  the  women,  when  having  their  monthly  sickness,  to  drop  all  work, 
absent  themselves  from  their  lodges,  and  remain  in  perfect  rest  as  long 
as  the  discharge  continues."  Measurements  made  by  Holder  indicate 
that  the  average  height  of  the  Indian  woman  is  5  feet  3^  inches; 
chest,  32-|  inches;  waist,  39f^  inches;  hips,  34|-|  inches.  The  measure- 
ments of  the  perfect  form  of  the  civilized  woman  are  given  as  follows: 
Height,  5  feet  5  inches;  bust  measure,  33  inches;  waist,  26-|  inches;  hips, 
35  inches.  It  would  not  seem  from  this  comparison  that  civilization 
is  producing  the  disastrous  results  with  which  it  is  accredited.  On  the 
contrary,  there  are  many  evidences  of  an  improvement  in  the  physique 
of  women  of  the  civilized  type,  in  which  improvement  the  genital 
organs  are  no  doubt  participating. 

Education. — Education  of  the  conventional  type  has  been  held  re- 
sponsible for  many  of  the  ills  peculiar  to  women.  This  criticism  had 
much  more  point  and  force  a  few  decades  ago  when  the  convent, 
with  its  seclusion  and  sedentary  habits,  determined  the  character  of 


GENERAL   ETIOLOGY  OF   DISEASES  OF   WOMEN  7 

women's  education.  The  present,  however,  may  be  designated  as  the  ra- 
tional epoch  in  women's  education — one  in  which  they  receive  the  max- 
imum of  physical,  mental,  and  moral  benefit  with  the  minimum  of  in- 
jury. The  most  hopeful  feature  of  the  i^resent  regime  is  the  tendency  on 
the  part  of  educators  to  study  and  regard  the  capacities  and  require- 
ments of  the  individual  pupil.  Eecognition  is  given  to  the  primary  bio- 
logic law  of  the  antagonism  between  growth  and  genesis;  and  the  effort 
is  made  in  all  advanced  institutions  of  learning  to  adjust  the  curricula 
to  the  needs  of  the  growing  girl  at  different  periods  of  her  life.  The 
doctrines  of  Froebel  and  Pestalozzi  have  relieved  educational  methods 
of  much  of  their  subjectivity,  with  the  result  that  more  attention  is 
given  to  the  education  of  the  muscular  system  and  the  special  senses;  the 
book  has  largely  yielded  to  the  laboratory,  and  the  cloister  to  the  open 
volume  of  Nature.  Potter  {New  York  Medical  Journal,  1891),  recognis- 
ing some  of  the  yet  remaining  defects  of  the  educational  system,  sug- 
gests that  for  girls  between  twelve  and  sixteen,  study  hours  or  school 
work  be  restricted  to  four  hours  daily;  that  during  each  catamenial  pe- 
riod the  recitation  room  should  be  avoided;  that  during  this  period  girls 
should  indulge  in  much  mental  and  bodily  repose;  and  that  during  the 
school  period  especially,  which  is  also  the  period  of  most  active  growth, 
girls  should  be  provided  with  an  abundance  of  wholesome  food  and  be 
instructed  in  the  most  careful  dietetic  habits,  special  stress  being  laid 
upon  a  full  morning  meal.  The  dress  should  be  constructed  with  ref- 
erence to  relieving  the  waist  line  of  all  weight  and  pressure.  He  lays 
great  stress  upon  the  rule  that  no  girl  should  enter  a  boarding  school 
where  the  building  is  more  than  two  stories  high,  and  that  stair  climb- 
ing, at  this  developmental  period  of  life,  should  be  reduced  to  the 
minimum.  Sir  J.  Crichton  Browne  urges  that  there  are  sexual  brain 
differences  betAveen  men  and  women  which  militate  against  the  latter 
in  higher  education.  While  he  admits  that  there  are  no  trustworthy 
data  for  the  estimation  of  the  normal  brain  weight  of  healthy  natives  of 
Great  Britain,  he  bases  his  conclusions  upon  the  study  of  the  brain  of 
insane  subjects,  with  the  result  that  he  finds  the  average  excess  of  male 
over  female  brain  weight  to  be  4.5  ounces,  or,  if  allowance  is  made  for 
the  difference  in  bodily  height,  the  excess  of  the  male  over  the  female 
brain  weight  is  reduced  to  1.05  ounces.  Sir  James  Browne  asserts  that 
the  posterior  brain  development  is  greater  in  woman,  that  the  convolu- 
tions have  a  similar  pattern,  and  that  her  left  brain  weighs  relatively 
less  than  her  right;  but  there  is  a  marked  difl^erence  in  the  distribution 
of  the  blood  to  the  brain  in  the  two  sexes,  and  from  these  observations 
the  conclusion  is  drawn  that  women  are  not  fitted  for  the  same  educa- 
tional tasks  as  are  men.  The  whole  argument  is  misleading,  first,  from 
the  fact  that  the  observations  were  made  upon  the  brains  of  insane  peo- 
ple; next,  that  they  were  not  sufficiently  numerous  to  justify  a  general 
conclusion;  and,  finally,  that  the  results  of  higher  education  among 
women  show  that  they  improve  physically  as  well  as  mentally,  rather 
than  deteriorate,  under  its  influence.     The  last  statement  is  confirmed 


8  A  TEXT-BOOK  OF   GYNECOLOGY 

by  Dr.  Mary  Dixon  Jones,  who,  as  a  former  principal  of  a  young  ladies'' 
seminary,  and  latterly  a  successful  practitioner  with  an  extensive  clien- 
tele among  women,  asserts  that  menstrual  disturbances  are  of  rare  occur- 
rence, and  that  symptoms  referable  to  the  pelvis  are  but  seldom  com- 
plained of  among  young  women  students.  The  after  life  of  such  stu- 
dents indicates  as  good  an  average  state  of  health  and  as  high  a  degree 
of  fecundity  as  among  any  other  class.  It  is  not  apparent  why  intellec- 
tual occupation  during  the  period  of  pubescence  should  interfere  with 
sexual  growth  any  more  among  girls  than  among  boys. 

Personal  Habits. — That  personal  habits  have  much  to  do  in  the 
causation  of  pelvic  diseases  can  not  be  denied.  Habitual  errors  of  diet 
resulting  in  constipation;  general  physical  inactivity  inducing  slug- 
gishness of  the  splanchnic  circulation;  and  habits  of  dress  seriously 
constricting  the  waist  and  imposing  weight  upon  the  pelvic  viscera,  are 
all  to  be  taken  into  account.  The  corset,  however,  as  an  article  of 
dress  is  not  to  be  unqualifiedly  condemned;  on  the  contrary,  if  loosely 
applied,  it  serves  as  a  protection  rather  than  otherwise  to  the  underlying 
viscera.  More  serious  criticism  should  be  directed  to  the  deficiencies 
of  dress  of  the  neck,  shoulders,  arms,  and  legs.  The  influence  of  cold 
upon  these  more  or  less  extensive  areas  can  not  but  have  a  tendency  to 
produce  internal  engorgements.  Habits  of  outdoor  exercise,  now  more 
or  less  prevalent,  evince  a  hopeful  tendency  in  the  hygiene  of  women. 
Equestrian  exercise,  the  bicycle,  and  golf,  are  all  calculated  to  improve 
the  physique  of  those  who  temperately  participate  in  them.  While 
this  is  true,  it  should  not  be  forgotten  that  excessive  activity  in  these, 
as  in  other  wholesome  sports,  may  be  provocative  of  damage. 

Occupation. — The  modern  extension  of  woman's  activities  has 
brought  with  it  more  or  less  of  a  penalty  in  the  form  of  genital  diseases 
induced  by  her  occupations.  It  was  not  to  be  exjjected  that  women 
could  adjust  themselves  without  damage  to  labours  which,  through 
generations,  had  been  arranged  for  men;  nor  could  it  have  been  ex- 
pected that  the  several  vocations  could  be  at  once  so  remodelled  as  to 
suit  them  to  women's  phj^sical  capacities.  Clerking  in  stores,  with  its 
long  hours  of  uninterrupted  standing,  employment  in  offices  that  were 
not  provided  with  proper  lavatory  facilities,  work  in  factories  with  im- 
perfect ventilation,  and  the  carrying  of  heavy  burdens,  are  among  the 
examples  which  illustrate  the  influence  of  occupation  as  a  cause  of  pel- 
vic disease  in  women.  The  peasant  women  of  continental  Europe  work 
side  by  side  with  the  men  in  nearly  all  occupations,  and  they  are  espe- 
cially given  to  carrying  heavj^  burdens  upon  the  head,  as  is  true  of  the 
American  negro  in  the  South.  All  these  classes  furnish  examples  of 
uterine  displacements — especially  procidentia  and  its  attendant  evils. 
The  relative  robustness  of  the  European  peasant  women  is  largely  a  fic- 
tion. The  modern  household  has  many  features  that  have  etiological 
bearings  upon  this  class  of  diseases.  The  thoughtless  construction  of 
houses,  carrying  with  it  the  necessity  of  excessive  stair  climbing;  the 
totally  unnecessarily  great  weight  of  household  utensils  that  must  be 


GENERAL  ETIOLOGY  OP   DISEASES  OP  WOMEN  9 

handled  by  women;  and  the  performance  of  overhead  tasks,  many  of 
them  unnecessary,  are  causes  to  be  taken  into  account.  The  sewing 
machine,  while  a  great  mercy  to  womankind  in  general,  is,  by  its  abuse, 
a  fruitful  source  of  mischief  to  those  whom  it  was  designed  to  benefit. 

Diseases. — Aside  from  gonorrhoea  and  syphilis,  mentioned  in  an- 
other paragraph,  other  diseases  are  provocative  of  genital  disorders  in 
women.  Miiller,  of  Munich  {C entralblatt  fur  Gyndkologie,  1890),  has 
reported  several  cases  in  which  miscarriages  were  induced  by  la  grippe. 
The  influence  of  the  same  disease  upon  the  genital  organs  is  noted  by 
the  same  author,  who  finds  that  in  a  large  number  of  cases  it  provokes 
either  metrorrhagia,  menorrhagia,  or  aggravation  of  sexual  diseases 
already  existing.  Erysipelas  may  result  in  bacterial  invasion  and  con- 
sequent suppuration  within  the  pelvis  and  in  puerperal  fever.  ISTeuras- 
thenia,  a  distinctly  constitutional  state,  may  occasion  symptoms  which 
Goodell  appropriately  designated  as  nerve  counterfeits  of  genital  dis- 
eases. Engorgements  of  the  liver,  from  whatever  cause  arising,  may 
produce  disturbance  of  the  portal  circulation  to  a  degree  that  will 
induce  passive  congestion  of  the  pelvic  viscera.  Constipation  is  a  fre- 
quent cause  of  functional  disturbance  of  the  ovaries  and  uterus. 

Copulation. — The  sexual  relation  fulfils  the  meaning  implied  in 
the  creation  of  two  sexes.  It  is  distinctly  a  physiologic  function,  yet 
errors  in  its  establishment  and  practice  frequently  cause  injury  and 
disease  in  women.  Coition,  done  abruptly  for  the  first  time,  particularly 
if  attempted  by  a  male  organ  disproportionately  large,  may  produce  lac- 
erations and  dangerous  hemorrhage.  A  penis  of  inordinate  length  may 
penetrate  a  woman  so  far  as  to  exercise  undue  violence  upon  the  uterus 
and  adnexa,  and  thereby  sooner  or  later  induce  disease  of  those  organs. 
If  practised  too  frequently,  or  in  the  absence  of  inclination  on  the 
part  of  the  woman,  or  if  repeatedly  completed  by  the  man  before  an 
orgasm  is  experienced  by  the  woman,  it  sooner  or  later  becomes  a  mere 
source  of  mechanical  irritation  to  the  latter.  Prostitutes  suffer  greatly 
in  consequence  of  the  nonamatory  character  of  their  sexual  relations, 
although  in  such  cases  the  constant  possibility  of  infection  as  a  com- 
plicating causative  factor  must  be  held  in  mind.  Coitus  reservatus  when 
indulged  in  by  the  female  has  a  tendency  to  increase  to  an  abnormal 
degree  the  turgescence  of  the  organs.  Van  de  Warker  made  a  critical 
study  of  forty-two  women  of  the  once  notorious  Oneida  community, 
which  seemed  to  have  been  organized  chiefly  with  reference  to  the 
practice  of  coitus  reservatus,  especially  by  the  male,  but  under  condi- 
tions of  promiscuity.  He  found  no  greater  prevalence  of  sexual  disease 
there  than  elsewhere,  nor  was  he  able  to  find  diseased  conditions  which 
he  could  attribute  to  the  sexual  habits  of  the  commimity.  Sexual 
anfpMhesia,  of  frequent  occurrence  in  women,  is  a  cause  of  unhappiness 
and  pbysical  injury.  Sexual  perversions  are  to  be  considered  in  the 
light  of  both  cause  and  consequence  of  genital  disease.  Masturbation 
is  often  caused  by  a  pre-existing  local  irritation  of  the  vagina  or  puden- 
fliirn,  or  by  arlbosions  of  tlio  clitoris  to  the  prepuce,  and  it  as  frequently 


10  A   TEXT-BOOK  OP   GYNECOLOGY 

causes  similar  disturbances.  It  is  highly  probable  that  there  is  no  form 
of  sexual  perversion  that  is  not  associated  with  more  or  less  congestion 
of  the  genital  organs  which  remains  after  the  act,  whatever  it  may  be,  is 
completed. 

Prevention  of  Conception. — Malthus  formulated  a  doctrine  which 
assumed  to  justify  the  limitation  of  families  by  the  prevention  of  con- 
ception. Practices  having  this  object  in  view  have  been  known  since 
Onan  spilled  his  seed  upon  the  ground.  Many  accessory  practices,  how- 
ever, have  come  into  vogue  in  modern  times, none  of  which  are  destitute 
of  serious  consequences.  The  use  of  the  vaginal  douche  immediately 
after  intercourse,  the  use  of  a  sponge  within  the  vagina  for  absorbing 
the  semen,  the  "  womb  caps,"  condoms,  are  all  damaging  expedients. 
If  it  is  granted  that  their  local  physical  effects  are  not  deleterious,  the 
fact  still  remains  that  their  employment  implies  a  psychic  state  inim- 
ical to  the  perfectly  normal  performance  of  the  copulative  act.  Coitus 
reservatus  is  generally  more  damaging  to  the  male  than  to  the  female. 

Criminal  Abortion. — There  has  been  no  time  within  the  known  his- 
tory of  the  human  race  when  women  have  not  sought  to  avoid  mater- 
nity. The  induction  of  abortion  as  a  means  of  limiting  reproduction 
was  known  and  practised  by  the  Egyptians,  the  Greeks,  and  the 
Eomans.  x\lthough  certain  social  theorists  have  enunciated  the  prin- 
ciple of  justifiable  foeticide,  it  remains  an  unproved  assumption  that 
the  practice  is  more  prevalent  to-day  than  in  previous  periods.  That 
it  is  prevalent  to-day,  however,  there  is  no  denying;  nor  can  the  dele- 
terious results  of  the  practice  upon  the  reproductive  organs  of  women 
be  ignored.  Infections  induced  in  this  way,  when  not  fatal,  almost 
always  destroy  fecundity  and  render  relief  by  surgical  means  im- 
perative. 

Childbirth. — j\Iany  of  the  injuries  and  diseases  of  women  have  their 
origin  in  childbirth.  The  relatively  large  cranial  development  of  chil- 
dren borne  by  civilized  women,  rather  than  any  other  one  circumstance, 
tends  to  increase  the  difficulties  and  dangers  of  parturition.  Infec- 
tion occurring  in  childbed,  resulting  in  puerperal  fever,  or  in  infection 
of  the  endometrium  or  the  Fallopian  tubes,  is  yet  of  too  common 
occurrence,  although  it  is  encountered  with  less  frequency  since  the 
bacterial  character  of  puerperal  infections  has  become  better  under- 
stood. The  recent  great  improvement  in  the  obstetric  art  has  already 
resulted  in  the  practical  disappearance  of  vesico-vaginal  fistula  and  in 
the  diminished  frequency  of  both  cervical  and  perineal  lacerations. 
These  conditions,  however,  are  yet  encountered  as  the  demonstrable 
results  of  parturition. 

The  Social  Evil. — The  social  evil  has  long  been  recognised  as  re- 
sponsible for  many  of  the  physical  infirmities  of  women.  This  evil, 
which  has  existed  from  the  remotest  antiquity  and  which  will  continue 
to  exist  as  long  as  the  race  suiwives,  is  a  necessary  incident  of  social 
organization.  It  is  properly  recognised  by  all  sociologists  as  an  in- 
evitable feature  of  social  evolution.     In  dealing  with  it,  therefore,  it 


GENERAL   ETIOLOGY   OF  DISEASES  OF   WOMEN  H 

is  important  at  the  outset  to  recognise  it  as  an  abiding  fact  rather  than 
as  an  evanescent  theory.  In  what  way,  therefore,  does  it  exercise  a 
deleterious  physical  influence  upon  society  at  large?  The  answer  is 
that  it  works  its  mischief  by  the  dissemination  of  the  two  great  vene- 
real diseases,  syphilis  and  gonorrhoea. 

Syphilis  causes  disease  of  the  genital  organs  of  women  chiefly  from 
the  fact  that  it  is  communicated,  for  the  most  part,  in  the  act  of  inter- 
course, and  that  the  primary  sore  manifests  itself  in  the  genitalia.  This, 
as  a  rule,  is  not  an  especially  serious  matter,  although  it  may  lead  to 
the  graver  constitutional  complications  characteristic  of  the  disease. 
In  its  hereditary  form  it  is  liable  to  manifest  itself  in  defective  develop- 
ments and  in  temperamental  deficiencies,  both  of  which  may  be  mani- 
fested in  defective  functional  capacity  of  the  genital  organs.  The 
manifestations  of  this  disease  in  relation  to  the  difi:erent  organs  will  be 
considered  in  their  appropriate  places  in  this  work. 

Gonorrlicea,  more  than  any  other  one  disease,  is  responsible  for  those 
complications  in  women  which  are  destructive  of  her  reproductive  ca- 
pacity, which  produce  organic  disintegrations,  and  which  demand  sur- 
gical interference  for  their  relief  or  cure.  Before  JSToeggerath  demon- 
strated that  the  gonococcus  (see  Microccocus  gonorrhoece  under  Sepsis) 
was  the  essential  infectious  element  in  the  vast  majority  of  intrapelvic 
suppurations,  tubal  and  otherwise  (see  Pyosalpinx),  gonorrhoea  was 
looked  upon  as  a  local  and  comparatively  trivial  affection,  involving  the 
vagina  and  external  genitalia.  Since  that  time,  however,  the  medical 
profession  has  come  to  recognise  it  as  the  most  dangerous  disease  of 
frequent  occurrence  with  which  woman  is  afflicted,  cancer,  of  course, 
being  excepted.  This  assertion  finds  ample  confirmation  in  the  etiology 
and  pathology  of  inflammatory  diseases  of  women  as  presented  in  sub- 
sequent chapters. 

The  social  evil  being  recognised  as  a  fixed  and  inevitable  fact,  and 
the  dissemination  through  it  of  venereal  disease  being  so  destructive 
to  women,  it  is  the  manifest  duty  of  society  to  subject  prostitution  to 
the  most  rigorous  supervision.  The  medical  profession  owes  it  to  itself, 
and  to  the  humane  objects  to  which  it  stands  consecrated,  to  use  its 
influence  to  secure  the  legal  regulation  of  that  evil  which  society  has 
proved  itself  unable  to  suppress. 


CHAPTER  III 

GENERAL  PATHOLOGY  OF  THE  FEMALE  GENERATIVE 

ORGANS 

Local  pathology  conforms  to  general  pathologic  laws — Peculiarities  depending 
upon  difEerentiated  functions — Menstruation — Ovulation  and  gestation  in  their 
relation  to  pathologic  states — The  poise  of  the  uterus  and  its  variation — Bac- 
terial origin  of  inflammatory  diseases  of  the  female  genitalia — Tuberculosis — 
Syphilis — Trophic  changes — Neojilasms. 

Local  Pathology  conforms  to  General  Pathologic  Laws. — The  gen- 
eral pathology  of  the  female  organs  of  generation  in  many  respects  does 
not  differ  from  the  general  morbid  anatomy  and  physiology  of  other 
parts  of  the  body.  Simple  and  specific  inflammations,  local  bacterial 
infections,  benign  and  malignant  tumours,  hypertrophy  and  atrophy, 
degenerations  and  other  secondary  changes,  complications,  and  sequels, 
follow  the  same  pathologic  laws  and  types  as  are  observed  elsewhere  in 
the  organism.  There  may  be  minor  differences,  but  these  variations  do 
not  involve  any  fundamental  change  in  principle.  Of  such  slight  devia- 
tions from  the  ordinary  there  may  be  mentioned  unusual  degrees  of 
glandular  hypertrophy,  often  developing  after  slight  inflammatory  irri- 
tation, such  as  we  find,  for  instance,  in  the  mucous  membrane  of  the 
uterus.  There  are  tumours,  ordinarily  very  malignant  in  type,  which 
in  some  parts  of  the  female  genitalia — the  ovary,  for  example — may 
exist  for  a  long  time  without  involving  neighbouring  structures  or 
giving  rise  to  metastases.  On  the  other  hand,  tumours  histologically  of 
a  benign  type  may  produce  purely  mechanical  disturbances  by  their 
rapid  growth,  location,  or  otherwise,  which  may  endanger  or  even  take 
the  life  of  the  patient.  There  are,  however,  also  quite  a  number  of 
morbid  phenomena  and  conditions  to  which  the  female  only  is  subject, 
and  which  must  be  studied  from  a  strictly  specialistic  standpoint,  with- 
out, of  course,  losing  sight  of  the  great  general  principles  of  pathology. 

Peculiarities  depending  upon  Differentiated  Functions. — The  fe- 
male genitalia  in  the  human  race  perform  such  specific  and  well-differ- 
entiated physiologic  functions  that  we  should  expect  to  find  in  them 
disturbances  unknown  elsewhere.  Such  is  the  case;  for  the  functions 
of  menstruation,  ovulation,  and  pregnancy,  are  often  disturbed  in  their 
exercise  by  underlying  abnormal  changes  which  call  for  particular 
attention. 

Menstruation  in  its  Relation  to  Pathologic  States. — Menstruation 
brings  about  a  cycle  of  profound  though  transitory  changes  in  the 
12 


GENERAL  PATHOLOGY  OP  FEMALE  GENERATIVE  ORGANS  13 

uterus.  Congestion  to  a  degree  which  an^^where  else  in  the  body  wouhl 
be  abnormal,  and  actual  hemorrhage,  would,  of  course,  be  pathologic 
in  any  other  organ  but  the  female  genitalia.  It  was  formerly  gen- 
erally held  that  the  uterus  in  menstruation  shed  its  whole  mucous 
membrane,  this  being  regenerated  from  what  little  remained  of  the 
glandular  epithelium.  Herzog,  who  has  carefully  examined  several 
menstruating  uteri  obtained  by  operation  from  living  subjects  and  not 
post-mortem,  agrees  with  Mandl,  Westphalen,  Gebhard,  and  others, 
who  within  the  last  few  years  have  maintained  that  the  uterus  does 
not  shed  its  mucous  membrane  in  menstruation,  but  only  loses  some 
of  the  surface  epithelium.  It  being  conceded  that  this  view  is  cor- 
rect, there  are  then  still  present  during  and  shortly  after  menstrua- 
tion some  small  patches  of  mucous  membrane  denuded  of  surface  epi- 
thelium. This  condition  certainly  favours  bacterial  invasion  whenever 
microbes  are  present,  and  a  locus  minoris  resistentice  is  thus  created 
periodically  in  the  female  which  does  not  exist  in  the  male.  Morbid 
subjective  symptoms,  the  disturbances  of  beginning  menstruation,  dys- 
menorrhoea,  menorrhagia,  amenorrhoea,  and  vicarious  menstruation,  are 
phases  of  pathologic  phenomena  necessarily  peculiar  to  the  female,  and 
that  are  considered  in  detail  in  the  section  on  Menstruation. 

We  thus  find  that  the  function  of  menstruation  may  and  does  carry 
with  it  to  the  female,  dangers  and  pathologic  conditions  from  which  the 
male  is  exempt. 

Ovulation  in  its  Relation  to  Pathologic  States. — ^We  likewise  find 
the  same  to  be  true  with  reference  to  ovulation.  In  it  the  physiologic 
processes  and  the  accompanying  tissue  changes  are  of  a  type  which 
may  be  well  called  quasi-pathologic.  Paradoxical  as  it  may  appear,  it 
may  be  well  said  that  nowhere  in  the  body  do  we  have  a  physiologic 
process  with  such  typical  pathologic  features  as  are  found  in  ovulation. 
When  a  Graafian  follicle  has  become  mature  and  has  approached  the 
surface  of  the  ovary  there  occurs  at  the  time  of  ovulation  a  break  in 
the  continuity  of  the  ovarian  tissue,  a  rupture,  accompanied  by  a  hemor- 
rJiage,  which  may  be  more  or  less  extensive.  The  gap  so  formed  is  in 
the  normal  course  of  events  closed  by  the  formation  of  cicatricial  tissue, 
derived  from  connective-tissue  elements.  Herzog,  who  has  studied  the 
normal  and  pathologic  anatomy  of  the  corpus  luteum,  agrees  with  Clark 
(Archiv  fur  Anatomie  und  Physiologie, 1898), who  has  recently  reaffirmed 
the  view  that  the  lutein  cells  are  not  epithelial  cells  derived  from  the 
zona  granulosa,  but  connective-tissue  elements  derived  from  the  theca 
interna  folliculi.  The  processes  of  rupture,  hemorrhage,  and  cieatri- 
cial-tissue  formation,  are,  with  this  single  exception,  entirely  patho- 
logic. (We  will  liere  neglect  uterine  menstrual  hemorrhage,  which  is  of 
a  difl'ei'ent  chai'actcr  altogether.)  In  the  ovary  we  find  them  as  normal 
features  of  a  purely  physiologic  process.  It  is  obvious  how  easily  these 
fjiiaKi-|);i1  liologie  y)r()(;(;ssos  may  overstep  their  physiologic  limits  and 
lead  to  truly  morbid  conditicms,  such  as,  for  instance,  marked  cicatri- 
cial contractions  with  general  premature  atrophy  of  the  ovary.     Dan- 


14  A  TEXT-BOOK  OF   GYNECOLOGY 

gers  of  ovulation  to  the  female  organism  are  also  to  be  looked  for  in 
another  direction.  The  normal  living  cells  of  the  organism  all  pos- 
sess more  or  less  the  power  to  resist  bacterial  invasion.  In  ovulation, 
however,  we  have,  formed  in  the  female  organism  right  in  the  perito- 
neal cavity,  a  blood  coagulum,  a  focus,  not  consisting  of  living  cells, 
but  of  a  dead  culture  medium,  which  at  the  body  temperature  is  so 
notoriously  favourable  to  the  development  of  pathogenic  micro-organ- 
isms. It  has  been  said  above  that  menstruation,  in  consequence  of 
slight  denudation  of  the  uterine  mucous  membrane,  creates  here  a 
locus  minoris  resistentice  for  bacterial  invasion.  This  is  true  in  a 
still  higher  degree  with  reference  to  the  formation  of  the  blood  coagu- 
lum in  an  open  cavity  of  the  ovary.  Herzog,  in  studying  the  histology 
and  bacteriology  of  a  number  of  cases  of  ovarian  abscess,  was  struck 
by  the  observation  that  in  the  large  majority  of  cases  one  is  able  to  dem- 
onstrate that  the  abscess  wall  contains  elements  of  the  corpus  luteum. 
In  other  words,  these  abscesses  represent  an  infection  of  the  corpus- 
luteum  cavity  Avith  pus  formation  (empyema  of  the  corpus-luteum  cav- 
ity). The  proliferative  processes  in  the  normal  adult  body,  as  a  rule,  do 
not  lead  to  the  formation  of  newly  organized  tissues.  They  only  sub- 
stitute tissue  elements  which  in  the  cycle  of  metabolic  changes  have 
become  senile,  undergo  dissolution,  or  are  shed,  as  the  case  may  be, 
and  have  to  be  replaced  by  younger  elements. 

In  the  ovary,  during  sexual  activity,  with  the  ripening  of  the  G-raa- 
iian  follicle  we  have  constantly  a  process  of  real  new  tissue  formation 
which,  as  a  rule,  stojos  onl}'^  during  pregnancy,  but  which  may  even  then 
persist  (Herzog:  Superfcetation  in  the  Human  Eace.  Chicago  Medical 
Recorder,  vol.  xv,  1898).  It  is  not  improbable  that  the  normal  new 
tissue  formation  as  found  in  the  ovary  in  connection  with  the  maturing 
follicle,  stands  in  a  certain  relation  as  a  predisposing,  or  even  sometimes 
causative,  factor  in  the  development  of  neoplasms  so  frequently  found 
in  this  organ.  This  view  is  here  given  in  spite  of  the  well-known  fact 
that  most  neoplasms  of  the  ovary  are  very  likely  of  stromatogenous  and 
not  of  ovulogenous  origin.  Among  the  neoplasms  of  the  ovary,  to  be 
considered  more  in  detail  later,  there  is  one  of  a  most  unique  patho- 
logic histogenesis — namely,  the  dermoid  cyst  or  embryoma  ovarii.  Her- 
zog strongly  indorses  the  view  so  ably  advocated  by  Wilms  that  these 
neoplasms  are  always  of  ovulogenous  origin,  not  merely  derivatives  of 
ectodermal  inclusions,  and  that  they  represent  an  attempt  at  patho- 
genesis. 

Gestation  in  its  Relation  to  Pathologic  States. — The  most  impor- 
tant physiologic  function  of  the  female  genital  organs,  gestation,  leads 
to  numerous  pathologic  conditions  and  complications.  Most  of  these 
lie  outside  of  the  scope  of  this  work,  but  a  number  of  them  properly 
fall  within  the  domain  of  gynecology.  Minor  congenital  anomalies  of 
a  type  which  in  other  parts  of  the  organism  throughout  lifetime  may 
be  void  of  any  practical  moment,  when  found  in  connection  with 
female  genital  organs  may  become  of  the  greatest  pathological  impor- 


GENERAL  PATHOLOGY   OP  FEMALE   GENERATIVE   ORGANS     15 

tance.  Some  reference  has  already  been  made  to  this  point  when 
speaking  of  menstruation  in  the  presence  of  a  congenital  obstacle  to 
the  catamenial  flow.  Of  still  greater  practical  bearing  are  those  con- 
genital anomalies  which  become  responsible  for  ectopic  pregnancy. 
The  etiology  of  the  most  frequent  form  of  gestation  of  this  kind — 
namely,  tubal  pregnancy — is  as  yet  a  good  deal  contested  and  obscure. 
Herzog  is  of  the  opinion  that  in  a  large  percentage,  if  not  even  in  a 
majority,  of  cases,  congenital  anomalies  are  indeed  the  cause  of  ectopic 
gestation.  hSeveral  cases  have  been  reported  in  which  there  is  left  no 
doubt  as  to  an  etiology  of  this  kind.  (Henrotin  and  Herzog:  Anomalies 
du  Canal  de  Miiller  comme  cause  des  grossesses  ectopiques.  Revue  de 
gynecologie  et  de  cliirurgie  abdominale,  Paris,  1898. — Very  Early  Eup- 
ture  in  an  Ectopic  Gestation  in  a  Tubal  Diverticulum.  New  York 
Medical  Journal,  1899.) 

Pregnancy  also  furnishes  the  substratum  of  a  peculiar  kind  of  neo- 
plasm found  in  the  female,  the  syncytioma  malignum.  These  tumours, 
developing  during  or  shortly  after  pregnancy,  are  derived  from  foetal 
structures — namely,  the  chorion  epithelium,  comprising  the  layer  of 
Langhans  and  the  syncytium.  In  some  way  or  other  these  foetal  ecto- 
dermal structures  acquire  the  properties  of  a  malignant  tumour,  develop 
parasitic  properties,  invade  the  parental  structure,  primarily  the  sexual 
organs,  and  form  distant  metastases.  In  this  manner  embryonic  tis- 
sues may  become  the  starting  point  of  a  malignant  tumour  which  ulti- 
mately destroys  the  life  of  the  maternal  organism.  Here  we  have  again 
an  example  of  a  pathologic  event  directly  dependent  upon  a  function 
of  the  female  organs  of  generation,  an  occurrence  which  is  of  course 
impossible  in  the  male. 

The  Poise  of  the  Uterus  and  its  Variations. — Among  the  peculiar- 
ities of  the  female  sexual  organs  must  be  mentioned  the  delicate  man- 
ner in  which  the  uterus  is  balanced  and  held  in  position  by  the  gen- 
eral arrangement  of  the  parts  in  the  female  pelvis,  in  connection  with 
a  complicated  ligamentary  apparatus.  It  is  very  obvious  why  such  a 
complicated  arrangement  should  be  necessary,  when  we  consider  the 
changes  of  position  and  size  which  the  fruit  bearer  has  to  go  through 
during  the  sexual  life  of  the  female.  The  delicacy  of  balance  neces- 
sary from  physiologic  reasons  becomes  a  fruitful  source  of  morbid 
states.  A  very  important  and  voluminous  chapter  in  the  pathology  of 
the  female  sexual  organs  is  that  on  the  malpositions  of  the  uterus.  Of 
course,  these  malpositions  are  usually  not  of  a  primary  nature;  they  are, 
as  a  rule,  subsequent  to  other  morbid  changes.  But  these  morbid 
changes  per  se  are  often  very  insignificant,  and  a  long  train  of  patho- 
logic symptoms  and  conditions  is  only  brought  about  in  consequence 
of  the  changed  position  of  the  womb,  its  sequelae,  and  complications. 
(See  Uterine  Displacements.) 

Bacterial  Origin  of  Inflammatory  Diseases  of  the  Female  Genitalia. 
— If  we  now,  from  the  standpoint  of  nosology,  consider  the  general 
pathology  of  the  female  organs  of  generation,  inflammatory  diseases 


16  A  TEXT-BOOK  OF   GYNECOLOGY 

first  command  our  attention.  After  bacteriology  had  solved  quite  a 
number  of  questions  with  reference  to  general  and  local  infections  and 
inflammatory  conditions  in  various  parts  of  the  organism,  it  was  hoped, 
and  firmly  believed,  that  this  youngest  branch  of  pathology  would  also 
speedily  contribute  much  toward  showing  us  the  true  etiology  of  the 
great  variety  of  inflammatory  diseases  of  the.  female  genitalia.  The  ana- 
tomic arrangement  of  the  latter  makes  it  a  priori  very  probable  that 
bacterial  invasion  plays  a  predominating  role  as  a  causative  factor  in 
all  classes  of  inflammatory  diseases.  Doderlein,  commenting  upon  this 
point  with  reference  to  such  affections  of  the  uterus,  says:  "  Above  any 
site  in  the  body,  the  uterus  seems  to  be  the  place  favouring  bacterial 
invasion  and  colonization.  The  open  connection  between  the  uterus, 
the  vagina,  and  the  outside  world;  the  many  chances  for  transport  of 
germs  which  are  so  obvious,  particularly  during  sexual  life;  stagnating 
secretions  protected  against  desiccation  and  kept  at  a  brood-oven  tem- 
perature-— all  these  factors  unite  to  a  priori  impress  us  how  well  adapted 
the  interior  of  the  genitalia  is  for  bacterial  invasion  and  diseases  de- 
pendent upon  them."    (See  Sepsis.) 

Yet  it  has  been  found  that,  in  spite  of  all  these  apparently  favour- 
able factors,  the  internal  genital  organs  of  the  healthy  woman  are  not 
easily  reached  by  pathogenic  bacteria,  and  are,  as  a  rule,  sterile.  The 
vulva,  according  to  the  unanimous  verdict  of  all  investigators,  is  fre- 
quently the  seat  of  pathogenic  bacteria,  particularly  the  ubiquitous 
ordinary  pyogenic  micro-organisms.  The  vagina,  however,  in  healthy 
women  contains  pathogenic  bacteria  only  in  a  small  number  of  the 
cases  examined  under  the  proper  precautionary  measures  to  avoid 
contamination.  It,  on  the  other  hand,  in  healthy  women  always  har- 
bours a  great  many  nonpathogenic  bacteria.  Yet,  fully  virulent  patho- 
genic microbes,  introduced  experimentally,  as  has  been  done  by  Bumm, 
Menge,  Kronig,  Doderlein,  and  others,  are  speedily  killed  in  the 
healthy  vagina.  Clinical  and  other  experience  has  abundantly  shown 
that  the  vagina  under  certain  conditions  loses  its  protective  power  of 
"  self -purification."  Particularly  is  this  the  case  in  parturition  and 
immediately  after  delivery.  A  large  percentage  of  septic  inflammatory 
diseases  of  the  female  genitalia  may  be  traced  back  to  infection  in  par- 
turition. Such  septic  infection  may,  of  course,  also  be  easily  induced 
in  the  nonpuerperal  state  by  unclean  instruments  passed  into  the 
uterus. 

We  know  that  malpositions  or  tumours  of  the  uterus  are  responsible 
for  hyperplastic  inflammatory  reactions  of  the  endometrium.  Deep 
lacerations  of  the  cervix  so  frequently  occurring  in  parturition,  even 
without  a  manifest  septic  infection,  may  lead  later  on  to  chronic  in- 
flammatory changes  of  the  uterine  mucoiis  membrane.  In  other  cases 
of  endometritis  we  miss  every  tangible  anatomic  cause,  and  for  an 
attempt  at  explanation  we  must  turn  to  such  flimsy  causative  factors 
as  nutritional  and  circulatory  disturbances  of  unknown  origin — tropho- 
neurotic or  vasomotor  disturbances.    It  is,  however,  easy  to  understand 


GENERAL  PATHOLOGY   OF  FEMALE   GENERATIVE  ORGANS     17 

that  in  the  tissues  of  the  female  organs  of  generation  there  may  be 
■established  frequently,  without  the  aid  of  bacteria,  the  initial  stages  of 
inflammatory  processes  arising  directly  out  of  a  plus  of  the  physiologic 
functions.  Congestion  and  stasis,  or,  in  other  words,  dilatation  of  ves- 
sels and  diminution  of  the  velocity  of  the  current,  which  are  among 
the  first  steps  in  the  train  of  inflammatory  changes,  are  normally  found 
in  ovulation,  menstruation,  and  pregnancy. 

The  inflammatory  diseases  of  the  tubes  and  ovaries  are  often  of 
very  obscure  origin,  just  like  those  of  the  uterus.  This  is  particularly 
true  of  the  ovary.  In  it  we  meet  profound  pathologic  changes  of  this 
type,  which  baffle  every  attempt  to  get  at  their  true  cause  as  effectually 
as  they  resist  all  therapeutic  measures.  In  such  inflammations  of  the 
ovary  we  find  cases  with  grave  vessel  changes,  a  pathologic  process 
which  has  recently  been  described  under  the  designation  of  angeiodys- 
trophia  ovarii  (Bulius  and  Kretschmer). 

Tuberculosis  of  the  female  genital  organs,  which  may  be  a  primary 
or  a  secondary  process,  is  by  no  means  so  rare  as  was  formerly  believed. 
Some  parts  of  the  female  genitalia  are  invaded  frequently  by  the 
tubercle  bacillus.  Among  these  must  be  mentioned  preferably  the 
tube.  It  has  been  found  that  many  cases  of  salpingitis,  formerly  be- 
lieved to  be  simply  septic  in  character,  are  really  mixed  infections  in 
wdiich  the  tubercle  bacillus  is  present.  Even  the  ovary,  formerly  held 
to  be  practically  free  from  tuberculosis,  is  not  at  all  immune  but  is  oc- 
casionally infected.  In  the  uterine  mucous  membrane  we  find  tuber- 
culosis in  the  acute  miliary,  the  interstitial,  and  the  ulcerative  variety. 
Tuberculosis  of  the  muscular  coat  seems  to  be  rare,  yet  Herzog  has  seen 
a  case  in  which  the  whole  muscularis  was  literally  studded  with  tuber- 
cles.   (See  Tuberculosis  of  the  A^arious  Organs.) 

Syphilis  of  the  Female  Genitalia. — Syphilitic  manifestations  of  a 
primary,  secondary,  or  tertiary  type,  are  frequently  found  in  the  puden- 
dal organs,  but  very  little  is  known  about  syphilis  of  the  internal  geni- 
tal organs  except  the  occasional  localization  of  the  primary  sore  on  the 
portio  or  cervix.  Herzog,  who  has  studied  the  vascular  changes  of 
syphilis  (A  Contribution  to  the  Ilistopathology  of  Syphilis:  Chicago 
Medical  Recorder,  vol.  xiv,  1899),  is  of  the  opinion  that  certain  cases 
of  chronic  oophoritis,  in  which  no  other  causation  can  be  obtained,  and 
which  present  certain  vessel  changes  very  characteristic  though  not 
pathognomonic  of  syphilis,  may  be  due  to  either  the  acquired  or  the 
congenital  form  of  this  affection. 

Trophic  Changes. — Eeference  has  frequently  been  made  to  hyper- 
trophies occurring  in  the  female  genitalia.  Just  as  we  find  a  peculiar 
liability  to  hypertrophy  in  these  parts,  so  do  we  meet  atrophic  processes, 
some  of  which  have  so  far  baffled  all  endeavours  to  solve  their  etiology, 
as  is,  for  instance,  the  case  in  the  atrophic  condition  known  as  Icraurosis 
vulva?.  (See  Cutaneous  Diseases  of  the  Vulva.)  Of  course  all  normal 
physiologic  senile  changes  must  be  excluded  from  the  consideration  of 
morbid  atrophies,  the  most  interesting  of  which  are  those  of  the  uterus. 
3 


18  A   TEXT-BOOK  OF   GYNECOLOGY 

Normal,  transitory  lactative  hj^Derinvolution  may  lead  to  permanent 
premature  atrophy.  This  may  also  be  brought  about  by  a  number  of 
general  infectious  diseases,  abnormal  blood  states  (leucaemia),  or 
metabolic  affections  (diabetes).  Profound  puerperal  infection  is  the 
most  common  cause  of  partial  or  total  atrophy  of  the  uterus,  and  this 
may  lead  to  grave  local  and  general  disturbances.  (Bacon  and  Herzog: 
Fatal  Perfoi'ation  of  a  Uterus  Partially  Atrophied  Post-partum.  Amer- 
ican Journal  of  Obstetrics,  1899.) 

Neoplastic  Changes. — The  true  intrinsic  etiology  of  tumour  forma- 
tion in  the  female  genital  organs  is  as  obscure  to  us  in  these  parts  as 
it  is  elsewhere  in  the  organism.  We  know,  of  course,  that  the  female 
genitalia  are  in  an  unusually  high  degree  liable  to  become  the  seat  of 
neoplasms.  No  part  of  these  organs  is  free  from  tumour  formation, 
and  all  types  are  met  with.  Three  classes  of  new  growth  stand  out 
most  prominently.  The  horrible  frequency  of  carcinoma  of  the  uterus 
is  a  fact  only  too  well  known,  not  only  to  the  profession,  but  even  to 
the  laity. 

While  diseases  of  the  mamma  have  been  left  out  of  our  considera- 
tion entirely,  it  perhaps  deserves  mention  here  that  these  accessory 
sexual  organs  of  the  female  likewise  belong  to  those  organs  which  most 
frequently  develop  carcinoma.  The  second  class  of  tumours  which  show 
a  great  predilection  for  the  female  genitalia  is  formed  by  the  fibro- 
myomata.  Attempts  have  been  made  to  explain  their  frequent  devel- 
opment in  the  uterine  muscularis  upon  the  ground  that  the  structure, 
from  its  physiologic  changes  in  pregnancy,  has  an  intrinsic  tendency 
toward  the  new  formation  of  muscle  tissue.  But  this  seeming  explana- 
tion disregards  the  fact  that  while  we  have  in  pregnancy  an  enor- 
mous increase  in  the  bulk  of  the  muscularis,  it  is  one,  as  is  now  con- 
ceded, wliich  does  not  depend  upon  an  increase  in  the  number  of  the 
component  muscle  cells,  but  only  upon  an  increase  in  their  size.  The 
third  class  of  neoplasms  occupying  a  very  prominent  place  in  the 
pathology  of  the  female  organs  of  generation,  is  the  cysto-adenomata  of 
the  ovar3^  It  has  been  previously  mentioned  what  physiologic  reasons 
may  possibly  stand  in  some  causal  nexus  to  the  frequency  of  neoplastic 
formations  in  the  ovary.  In  the  cysto-adenomata  of  the  ovary  we  have 
epithelial  neoplasms  which  differ  greatly  in  some  respects  from  ade- 
nomata found  elsewhere.  The  latter,  as  a  rule,  have  a  great  tendency 
to  become  malignant  and  to  change  into  true  carcinomata.  This 
tendency  in  the  cysto-adenoma  of  the  ovary  is  rare.  (Henrotin  and 
Herzog:  Carcinoma  Developing  in  Primarily  Nonmalignant  Cysto- 
adenoma  of  the  Ovary.  Chicago  Medical  Recorder,  vol.  xvii,  1899.) 
Here  we  have  an  extensive  epithelial  proliferation,  which  in  other  parts 
of  the  body  is  almost  sure  to  lead  to  carcinoma,  but  which  in  the  ovary 
does  not  seem  to  carry  with  it  any  great  danger  of  developing  malig- 
nancy. Not  only  are  these  cysto-adenomata  very  common,  but  they  also 
often  occur  in  women  advanced  in  life,  and  they  may  exist  for  years 
and  decades  without  ever  changing  their  benign  type.    Pathologic  pro- 


GENERAL  PATHOLOGY  OP  FEMALE  GENERATIVE  ORGANS  10 

cesses  almost  unknown  in  other  parts  of  the  body,  but  fairly  often  seen 
in  the  female  in  connection  with  benign  epithelial  neoplasms,  are  the 
implantation  metastases  of  papillomatous  adenomata  of  the  ovary. 
These  metastases  are,  as  a  rule,  entirely  void  of  true  malignant  features, 
and  they  generally  disappear  after  the  removal  of  the  main  tumour. 

Another  fact  worth  remembering  in  connection  with  the  peculiar- 
ities of  the  pathology  of  the  female  genitalia,  is  the  comparative  fre- 
quency of  neoplasms,  particularly  of  a  sarcomatous  type,  in  the  female 
infant  and  child. 

In  closing  the  foregoing  considerations,  it  should  be  said  that  they 
do  not  pretend  to  furnish  a  full  and  exhaustive  general  description  of 
all  the  pathologic  phases  and  problems  encountered  in  connection 
with  the  female  genital  organs.  What  has  been  attempted,  is  to  give 
to  the  student  of  this  department  of  medicine  an  idea  of  the  special 
points  of  view  and  the  particular  physiological  considerations  from 
which  the  pathology  of  the  genital  system  of  the  woman  must  be  ap- 
proached, which  are  considered  in  detail  in  various  chapters  of  this 
book. 


CHAPTEE    IV 
GENERAL  THERAPEUTICS  OF   GYNECOLOGY 

General  medication — Serum  therapy — Local  medication — Balneotherapy — Sugges- 
tion— Electricity — Massage. 

General  Medication. — The  lines  along  which  modern  gynecology 
has  developed  have  been  so  distinctly  surgical  that  relatively  less 
attention  has  been  given  to  the  question  of  therapeutics.  The  error 
involved  in  this  tendency  is  shown  by  the  fact  that  the  female  genera- 
tive organs  are  in  close  vascular,  nervous,  and  tissue,  connection  with 
the  general  system,  of  which  they  are  as  distinctly  integral  parts  as  are 
the  eye,  the  ears,  or  other  organs  of  special  functions.  They  are  capable 
of  influencing  and  of  being  influenced  by  systemic  states;  and  they 
are  therefore,  to  a  certain  extent,  amenable  to  therapeutic  agencies. 
The  medical  aspect  of  gynecology  is  entitled  to  studious  consideration. 
The  deterioration  of  the  blood,  as  manifested  in  the  various  anaemias, 
often  finds  expression  in  disturbance  of  the  menstrual  function;  neu- 
rotic states  not  infrequently  cause  j^ainful  coition  and  dysmenorrhoea, 
while  hepatic  disturbances  produce  pelvic  hypersemias.  It  is  appar- 
ent, therefore,  that  any  therapy  which  will  relieve  the  initial  disturb- 
ance, will,  to  that  degree,  cure  its  results.  This  conception  of  the 
relation  of  the  functional  integrity  of  the  genital  organs  to  systemic 
states  or  to  other  anatomically  remote  diseases,  must  be  the  key  to  the 
intelligent  employment  of  remedial  agencies.  Thus,  a  simple  laxative 
may  relieve  ovarian  tenderness,  an  active  cholagogue  may  cure  a  con- 
gested uterus,  and  a  course  of  iron  and  arsenic  may  become  the  most 
potent  remedy  for  certain  functional  menstrual  deficiencies. 

That  remedies  given  by  the  stomach  exercise  in  any  important 
degree  an  elective  action  upon  the  nonpregnant  uterus  or  its  adnexa, 
is  open  to  doubt.  Ergot  and  the  bromides,  for  example,  given  as  rem- 
edies for  uterine  hyperplasia,  have  disappointed  expectation.  Laxa- 
tive agents,  however,  such  as  aloes  and  myrrh,  which  affect  the  lower 
alimentary  canal,  modify  the  functional  activity  of  the  generative 
organs  by  attracting  an  additional  volume  of  circulation  to  the  pelvis. 

The  most  valuable  general  remedy  in  the  treatment  of  the  diseases 
of  women,  is  rest.  This  should  be  looked  upon  just  as  if  it  were  a  mate- 
rial agency,  duly  catalogued,  and  described  in  the  materia  medica. 

Rest  in  this  sense  implies  not  only  physical  repose,  but,  so  far  as 
possible,  cessation  from  functional  activity.  To  realize  its  full  bene- 
20 


GENERAL  THERAPEUTICS  OP   GYNECOLOGY  21 

fit,  the  marital  relations  of  the  patient  should  be  for  the  time  discon- 
tinued, and  the  patient  herself  should  go  to  bed.  That  kind  of  rest 
which  patients  are  prone  to  take  by  donning  a  loose  gown  and  lounging 
here  and  there  about  the  house,  engaging  in  one  activity  after  another, 
amounts  practically  to  no  rest  at  all.  The  practitioner  will  do  well 
always  to  explain  in  minutest  detail  just  what  he  means  by  rest  when 
he  prescribes  it.  In  many  of  the  minor  acute  inflammations,  noninfec- 
tious in  character,  this  remedy  is  alone  sufficient  to  cure. 

Serum  Therapy. — The  treatment  of  gynecologic  conditions  by 
animal  extracts  was  introduced  by  Jouin  in  1895,  and  advocated  in 
America  by  Polk  {Medical  News,  January  11,  1899).  The  treatment  of 
diseases  of  the  uterus  and  adnexa  by  these  agents  is  under  advisement. 
Cures  of  amenorrhcea  due  to  obesity  are  reported  as  resulting  from  their 
use.  Polk  has  advocated  the  administration  of  thyroid  extract  for  the 
cure  of  uterine  fibroids,  and  has  reported  cases  which  seem  to  be  im- 
proved by  the  remedy.  The  treatment  seems  to  be  based  upon  the  well- 
known  reciprocal  trophic  relationship  existing  between  the  uterus  and 
the  thyroid  gland.  This  relationship  has  been  emphasized  by  Freund 
{CentraMatt  filr  Gyn'dkologie),  who  finds  that  swelling  of  the  thyroid 
merely  from  congestion  is  always  present  in  pregnancy,  and  also  during 
menstruation.  Wherever  there  is  energetic  or  persistent  irritation  in- 
volving the  uterine  muscles,  it  will  cause  a  persistent  swelling  of  the 
thyroid.  That  this  trophic  impulse  is  derived  from  the  uterus  rather 
than  from  its  adnexa,  is  shown  by  the  fact  that  ovarian  tumours  and 
tubal  dropsy  do  not  cause  enlargement  of  the  thyroid,  except  when  in 
rare  instances  they  encroach  upon  and  irritate  the  uterine  muscle. 
These  observations  are  in  accord  with  those  previously  made  by  J. 
Fischer,  who  affirms  and  demonstrates  not  only  the  influence  of  the 
uterus  upon  the  thyroid,  but  also  that  of  the  thyroid  upon  the 
uterus.  Women  with  goitre  generally  suflier  with  menorrhagia  and 
metrorrhagia;  extirpation  of  the  thyroid  is  followed  by  genital 
atrophy.  Myxoedema  in  women  is  generally  associated  with  amen- 
orrhcea. In  cretins,  there  is  a  diminution  and  often  an  entire  loss  of 
sexual  power.  Menstrual  disturbances  are  among  the  earliest  symp- 
toms of  exophthalmic  goitre.  These  facts,  long  since  established  in 
America  by  Jenks,  indicate  beyond  question  the  relationship  existing 
between  these  two  organs.  It  would  seem  that  an  extract  made  from 
the  thyroid  gland  of  the  sheep  and  ingested  into  the  human  system 
exercises  to  some  degree  a  modifying  influence  upon  the  uterus,  its 
nutrition,  and  functions.  The  extent  and  exact  character  of  this 
influence  remain  yet  to  be  determined.  Ovarian  extract  is  given  with 
the  object  of  stimulating  ovarian  activity  and  of  increasing  the  sexual 
af)petite.  Favourable  reports  of  its  use  have  been  made,  but  whether 
the  alleged  results  are  due  to  physical  or  psychic  influence  remains  to 
be  determined,  Protonuclein,  locally  applied,  is  unquestionably  a 
valuable  antistreptococcic  agent,  and  reports  are  abundant  indicating 
that  it  exercises  a  salutary  influence  over  the  nutrient  activities. 


22  A  TEXT-BOOK  OF   GYNECOLOaY 

Local  Medication. — Local  medication  consists  in  the  application  of 
remedies  directly  to  the  part  involved.  This  method  of  treatment  is 
of  great  importance  in  many  of  the  diseases  wliich  will  hereafter  be  con- 
sidered. Tlie  application  of  escharotics  to  an  inital  syphlitic  sore  and 
the  topical  use  of  an  antiseptic  solution  in  the  treatment  of  vaginal  gon- 
orrhoea, are  examples  in  point.  Among  the  remedies  thus  employed  for 
antiseptic  purposes,  the  chief  are  mercuric  bichloride,  carbolic  acid, 
lysol,  creolin,  and  potassium  permanganate.  Among  the  local  astrin- 
gents may  be  mentioned  the  salts  of  lead,  zinc,  and  even  iron. 
Boric  acid  is  a  favourite  with  many  i^ractitioners,  while  tannin  is  the 
vegetable  salt  of  greatest  importance  in  this  class  of  cases.  The  action 
of  astringents,  all  of  which  are  to  a  certain  extent  antiseptic  and  ger- 
micidal, is  to  influence  the  circulation  of  the  capillaries  upon  the 
tissues  to  which  they  are  applied.  They  are  frequently  of  question- 
able value,  and  always  of  less  value  than  those  agencies  which  have 
a  more  powerful  iiiHuence  in  desti-oyiiig  the  micro-organisms  upon 
which  depend  practically  all  of  the  inflammatory  diseases  in  the  mucous 
and  cutaneous  areas.  Hydrastinine,  a  comparatively  new  alkaloid,  de- 
rived from  the  hi/draslis  canadensis,  has  been  found  by  Falk  to  be  a 
valual)le  astringent,  when  used  in  ten-per-cent  solution  locally,  for  the 
treatment  of  uterine  hemoi-rhage.  Sedative  lotions  and  emollient 
applications  are  frequently  demanded  to  relieve  local  distress  in  the 
external  genitalia. 

Topical  a]>plicati()ns,  having  for  their  object  the  drainage  of  the  pel- 
vis by  exosmosis,  should  be  employed  in  practically  all  cases  of  acute  in- 
tlammation,  of  chronic  engorgement,  or  of  i)ersistent  exudation  within 
the  pelvis.  This  treatment  is  made  effective  by  virtue  of  the  hygroscopic 
proi)erties  of  glycerine.  This  agent  has  such  powerful  attraction  for 
water  that  it  abstracts  it  from  any  underlying  tissue  to  the  surface 
of  which  it  is  applied.  This  subject  will  be  treated  more  in  detail  in 
connection  with  pelvic  inflammations. 

Balneotherapy. — In  no  department  of  medical  practice  has  the  use 
of  water  proved  of  more  value  than  in  the  management  of  intrapelvic 
diseases  of  Avomen.  Emmet,  many  years  ago,  pointed  out  the  value  of 
the  vaginal  douche  and  demonstrated  its  rationale — the  water  at  a  tem- 
perature varying  from  105°  F.  to  120°  F.  is  applied  with  the  patient 
lying  on  her  back,  and  continued  for  a  period  of  twenty  minutes  at 
each  seance.  As  has  been  demonstrated  by  Emmet,  the  primary  influ- 
ence of  the  heat  thus  applied  is  to  dilate  the  capillaries  and  to  invite 
an  increased  supply  of  blood  to  the  parts.  In  the  course  of  ten  min- 
utes, however,  the  secondary  effect  of  the  heat  is  realized.  This  is 
characterized  by  blanching  of  the  parts,  a  contraction  of  the  capil- 
laries, and  a  marked  diminution  in  the  volume  of  the  local  circula- 
tion. This  treatment  should  be  repeated  at  least  twice  daily.  The 
results  are  invariably  a  marked  amelioration  of  local  engorgements, 
particularly  when  treatment  is  associated  with  rest  and  drainage  by 
osmosis.      Engelmann,    of    Kreuznach,    has    found    general    bathing 


GENERAL  THERAPEUTICS  OF   GYNECOLOGY  23 

under  scientific  supervision  to  be  a  remedy  of  great  value.  Asso- 
ciated with  friction,  it  acts  on  the  same  principle  as  a  counterirri- 
tant,  attracting  a  considerable  volume  of  tlie  circulation  to  the  surface, 
tliereby  relieving  splancbnic  congestions,  and,  by  stimulating  the  nerv- 
ous system,  becomes  an  active  promoter  of  absorption.  In  this  way  it 
becomes  valuable  as  a  remedy  for  clironic  exudates,  adliesions,  neo- 
plasms, and  in  the  treatment  of  amenorrhcea  due  to  obesity.  It  is 
contraindicated  in  acute  inllamuiatory  conditions.  Engelmann  says 
that  an  efficacious  bath  ought  to  contain  from  four  to  six  pounds  of 
common  salt  or  sea  salt,  and  also  from  two  to  five  pints  of  mother  lye  to 
four  hundred  pints  of  water.  The  temperature  of  the  batli  should  not 
exceed  95°  F.,  and  its  duration  should  not  exceed  half  an  hour.  The 
influence  of  such  a  bath  is  to  calm  the  pulse  and  respiration  and  to 
induce  sleep,  which  should  always  be  encouraged.  The  better  time  for 
taking  such  a  bath,  therefore,  is  just  before  bedtime. 

Suggestion. — Suggestion  as  a  therapeutic  agent  has  been  in  vogue 
since  the  Pastaphori  of  Egypt  practised  it  in  the  form  of  a  "  temple 
sleep,"  and  ever  since  the  healing  by  words  was  recorded  in  the  Mosaic 
writings,  or  in  the  pages  of  the  Zend-Avesta.  It  is  based  upon  the 
influence  of  mental  upon  physical  states,  and  while  it  has  never  re- 
ceived specific  recognition  as  a  distinct  agency  in  gynecologic  thera- 
peutics, it  is  nevertheless  a  remedy  of  unconscious  daily  application 
by  every  tactful  practitioner.  That  uterine  and  other  genital  disturb- 
ances exercise  a  perturbing  influence  upon  the  mind  is  a  matter  of 
constant  observation;  and  that  the  mind  diverted  from  the  seat  of  dis- 
comfort, or  thoroughly  impressed  with  the  thought  of  and  confidence  in 
the  recovery,  thereby  stimulates  the  organism  in  the  direction  of  health, 
is  a  fact  long  known  and  practised  by  the  profession.  Suggestion  may 
be  carried  not  only  to  the  unconsciousness  of  pain  due  to  local  j)hysical 
disturbances,  but  to  the  degree  of  anaesthesia  in  parts  that  are  not  the 
seat  of  disease.  So  powerful  is  this  agency  that  operations  may  be, 
and  have  been,  performed  painlessly  under  the  hypnosis  thus  induced. 
An  agent  of  such  power  should  be  subjected  to  more  critical  study 
than  has  yet  been  accorded  it  by  the  profession.    (See  Angesthesia.) 

Electricity. — Electricity,  in  the  form  of  faradism,  is  a  remedy  of 
some  value  when  adminstered  in  such  a  way  as  to  bring  the  nervous  and 
muscular  systems  under  its  influence,  when  it  acts  as  a  promoter  of 
metabolism  and  an  important  stimulant  to  the  nutrient  functions.  Ad- 
ministered locally,  under  antiseptic  precautions,  with  the  negative  pole 
in  the  uterus  and  the  other  upon  the  surface  of  the  abdomen,  it  has 
been  found  to  act  as  a  stimulant  in  restoring  the  functional  tone  of  that 
organ.  With  one  pole  in  the  vagina  and  another  in  the  groin  it  has 
been  found  to  relieve  neuralgic  conditions  within  the  pelvis.  Favour- 
able reports  have  been  made  of  its  use  in  catarrhal  endometritis.  There 
is  no  doubt  that,  judiciously  applied,  it  promotes  the  growth  of  the 
undeveloped  uterus,  for  which  purpose  the  intrauterine  electrode 
should  be  the  negative  one  and  that  placed  over  the  abdomen  or  over 


24  A  TEXT-BOOK  OF   GYNECOLOGY 

the  sacrum  should  be  the  positive  one.  It  has  been  found  to  promote 
the  absorption  of  effused  products  in  the  pelvis,  but  it  must  be  recog- 
nised as  a  dangerous  remedy  in  this  class  of  cases,  for  the  reason  that 
it  is  practically  impossible  in  many  of  them  to  determine  when  the 
exudation  does  or  does  not  depend  upon  purulent  infection,  in  the 
presence  of  which  electricity  should  not  be  used.  Electricity  in  the 
form  of  a  strong  current  causes  chemical  decomposition  of  the  tissues 
by  the  process  of  electrolysis,  by  which  the  acid  elements  are  attracted 
to  the  positive  pole  and  the  basic  elements  are  attracted  to  the  negative 
pole.  It  was  the  application  of  this  principle  that  induced  Apostoli,, 
of  Paris,  in  1884,  to  attempt  the  disintegration  and  absorption  of  uter- 
ine fibroids  by  the  use  of  strong  electric  currents.  He  began  by  using 
100,  which  he  finally  increased  to  250  milliamperes,  the  strength  of  the 
current  being  accurately  measured  by  a  galvanometer.  While,  in  many 
cases,  this  treatment  temporarily  arrested  hemorrhage  and  diminished 
the  size  of  the  growth,  its  general  results  have  not  been  accepted 
as  satisfactory  by  the  profession.  It  proved  to  be  painful,  causing,  in 
many  instances,  deep  eschars  on  the  abdominal  surface,  intractable 
peritoneal  adhesions,  infections  of  the  tumour,  septictemia,  and,  in 
some  cases,  death. 

Massage. — Massage  is  one  of  the  most  primitive  of  remedies,  and  is 
utilized  by  many  aboriginal  peoples.  Stanley  found  it  in  iise  among  the 
hordes  of  Africa;  Stevenson  found  it  in  use  among  the  JSTavajos;  it  was 
a  remedy  among  the  ancient  Chinese  and  the  Hindoos;  and  it  was 
employed  by  the  Greeks  and  Romans.  Hippocrates  mentioned  its  use 
in  diseases  of  the  joints.  In  the  great  renaissance  it  appeared  first  in 
France,  whence  it  spread  to  other  European  countries.  Billroth,  Es- 
marcli,  von  Mosetig,  Thiersch,  von  Bergmann,  von  Mosengil,  and  others 
recommended  it  highly,  first  in  diseased  conditions  of  the  extremities, 
and  finally  as  a  therapeutic  measure  in  diseases  of  the  internal  organs. 
In  the  form  of  general  massage  it  is  a  valuable  remedy  for  the  pro- 
motion of  metabolism  and  elimination,  especially  in  cases  of  the  neu- 
rotic type.  In  these  cases,  judiciously  applied,  it  tranquillizes  the  nerv- 
ous system,  induces  sleep,  and,  by  virtue  of  its  quality  as  a  form  of  pas- 
sive exercise,  it  promotes  nutrition.  It  is  of  special  value  as  an  adjunct 
to  the  "  rest  cure."  For  the  realization  of  its  greatest  benefits  it  must 
be  given  scientifically,  for  the  details  of  which  the  reader  is  referred 
to  the  various  manuals  on  the  subject.  Massage  is  contraindicated  in 
all  febrile  states  and  in  the  presence  of  acute  inflammation.  Dr.  G-eorge 
H.  Taylor  has  devised  a  method  called  by  him  vibratory  massage,  which 
is  utilized  by  means  of  specially  devised  apparatus.  The  method  shows 
great  ingenuity  and  a  scientific  conception  of  the  subject,  and  de- 
serves the  most  careful  consideration.  (See  New  York  Medical  Jour- 
nal, April  2,  1892.) 

Abdominal  massage  consists  in  the  manipulation  of  the  abdominal 
wall,  and  through  it  of  the  abdominal  organs,  for  the  purpose  of  pro- 
moting functional  activity  of  the  latter.     As  ordinarily  employed,  the 


GENERAL   THERAPEUTICS  OF  GYNECOLOGY  25 

patient  is  placed  in  the  recumbent  posture  with  the  abdominal  walls 
flexed,  when  with  the  hand  the  abdomen  is  kneaded.  This  general 
exercise  is  supplemented  by  manipulations  beginning  in  the  right  iliac 
fossjB  and  extending  upward  to  the  hepatic  flexure  of  the  colon,  thence 
across  to  the  splenic  flexure,  and  thence  downward  to  the  sigmoid,  the 
object  being  to  stimulate  the  colon  to  activity.  As  a  substitute  for  a 
manual  manipulation  of  the  abdomen,  Sahli  places  a  cannon  ball  on  the 
relaxed  abdominal  wall  and  rolls  it  around  in  various  directions,  and 
Ivanhoft'  has  suggested  a  substitute  in  the  form  of  a  hollow  wooden 
or  celluloid  globe,  partially  filled  with  shot.  A  shot-bag  has  been  simi- 
larly used  with  excellent  results.  AVhen  any  one  of  these  substitutes  is 
used,  its  application  should  be  concluded  by  rolling  it  repeatedly  over 
the  track  of  the  colon  from  the  cscum  to  the  sigmoid.  Abdominal 
massage,  to  be  most  effective,  should  be  given  half  an  hour  before 
breakfast  and  repeated  half  an  hour  after  breakfast.  By  its  employ- 
ment the  contents  of  the  abdominal  canal  are  moved  onward,  the 
portal  circulation  is  accelerated,  the  lymphatics  are  given  a  fresh 
impetus,  absorption  and  assimilation  are  promoted,  the  production  of 
gas  is  diminished  and  its  expulsion  facilitated,  and  the  splanchnic  sym- 
pathetics  are  stimulated,  while  all  the  nutrient  functions  participate  in 
the  benefit. 

Pelvic  massage  has  been  popularized  chiefly  through  the  influence 
of  Thure  Brandt.  It  consists  in  the  manipulation  of  the  pelvic  organs 
by  the  bimanual  method  with  the  object  of  correcting  displacements, 
of  curing  old  adhesions,  of  effecting  the  resorption  of  old  exudates,  of 
stretching  shortened  ligaments,  and  of  reducing  hyperplasias.  The 
patient  to  whom  it  is  to  be  ap^jlied  is  given  a  preliminary  treatment 
of  mild  laxatives  to  unload  the  rectum,  and  boroglyceride  tampons  in 
the  vagina  to  lessen  pelvic  engorgements.  The  patient  is  placed  in  the 
dorsal  position  with  her  knees  well  flexed;  the  vagina  is  thoroughly 
cleansed;  the  operator  inserts  the  index  finger  of  his  "handy"  hand, 
thoroughly  oiled,  into  the  vagina,  passing  it  well  up  behind  the  cervix; 
the  other  hand  is  placed  over  the  suprapubic  region.  At  this  juncture, 
and  before  any  special  manipulations  are  undertaken,  a  careful  biman- 
ual examination  of  the  pelvis  should  be  made,  a  precaution  which  should 
be  observed  at  the  beginning  of  each  seance.  If  points  of  recent 
engorgement  or  of  especially  acute  sensitiveness  are  discovered  the 
operator  should  desist.  If,  however,  no  such  contraindications  are 
found,  it  is  ]:)rescribed,  as  the  first  movement  of  the  massage,  to 
press  the  external  hand  over  and  behind  the  fundus  of  the  uterus, 
while  slight  downward  traction  is  exerted  by  the  tip  of  the  intravaginal 
finger,  the  object  being  in  all  movements  to  draw  the  uterus  gently 
toward  the  symphysis  pubis.  The  ovaries  are  treated,  when  discover- 
able, by  subjecting  them  to  a  similar  range  of  mobility.  Special  move- 
ments are  suggested  by  the  particular  conditions  that  may  be  discov- 
erefl.  A  seance  should  not  last  over  ten  minutes,  and  the  force  to  be 
employed,  both  in  amount  and  direction,  must  be  determined  at  the 


26  A   TEXT-BOOK   OF   GYNECOLOGY 

time  by  the  conditions  encountered  and  by  the  judgment  of  the  oper- 
ator. After  massage  a  boroglyceride  tampon  is  inserted,  and  if  the 
manipulations  have  been  at  all  painful  the  patient  should  remain  in  a 
state  of  repose  for  several  hours.  The  dangers  inherent  in  this  method 
of  treatment  are  so  many  that  it  has  been  largely  abandoned  by  those 
who  formerly  employed  it,  while,  on  theoretic  grounds,  it  has  been 
perhaps  too  unqualifiedly  condemned  by  those  who  have  never  tried  it. 
Its  chief  danger  consists  in  the  fact  that  the  exact  diagnosis  of  intra- 
pelvic  conditions  is  extremely  difficult,  and  that  consequently  massage 
is  liable  to  be  employed  with  fatal  results  in  conditions  in  which  it  is 
contraindicated.  iVmong  the  accepted,  but  sometimes  not  recognisable, 
contraindications  to  the  use  of  pelvic  massage,  are  acute  inflammatory 
processes;  the  presence  of  dilated  Fallopian  tubes;  ovarian  enlarge- 
ments; cystic  degeneration  in  either  the  ovaries  or  the  parovarium;  and, 
above  all,  the  presence  of  pus  in  the  pelvis.  (See  Diagnosis  of  Pyo- 
salpinx.) 


CHAPTER    V 
THE  GYNECOLOGICAL  ARMAMENTARIUM 

The  more  modern  principles  of  treating  wounds  have  led  to  marked 
modifications  in  the  surgeon's  armamentarium,  and  in  no  part,  per- 
haps, has  the  change  been  so  pronounced  as  in  the  kind  of  instruments 
used  in  operative  work.  The  day  of  instruments  with  elaborately 
carved  wooden  and  ivory  handles  is  past,  and  complicated  trocars  and 
tubular  needles  no  longer  have  a  place  in  our  instrument  cases.  The 
present  tendency  is  to  simplify  their  construction  as  much  as  possible 
and  to  use  no  greater  variety  than  is  absolutely  necessary.  The  choice 
of  instruments  must  necessarily  vary  with  the  predilections  and  train- 
ing of  the  individual  operator.  Certain  main  principles,  however, 
should  always  be  kept  in  mind.  The  surgeon  need  not  encumber  him- 
self with  such  instruments  as  are  seldom  needed,  or  with  a  multitude 
of  so-called  "  surgical  conveniences  "  and  "^  automatic  appliances."  He 
should,  however,  always  provide  himself  with  a  liberal  supply  of  the 
instruments  in  common  use,  in  order  to  be  prepared  for  emergencies. 
jSTone  should  be  retained  which  do  not  permit  of  easy  sterilization. 
Knives  should  have  smooth  metal  handles,  and  handle  and  blade  should 
be  in  one  piece.  Instruments  with  grooves,  depressions,  and  notches, 
are  to  be  avoided.  Good  hemostatic  forceps  with  smooth  blades  can 
now  be  obtained,  and  are  just  as  effectual  as  the  old  ones  with  grooved 
faces.  All  scissors,  forceps,  needle  holders,  and  the  like,  should  have 
simple  articulations,  so  that  the  different  parts  are  readily  separable. 
An  instrument  with  permanent  joints  can  not  be  kept  surgically  clean, 
and  should  therefore  not  be  tolerated.  With  our  present  methods  of 
sterilization,  instruments  made  of  steel  do  not  suffer  as  they  did  for- 
merly, and  if  properly  cared  for  should  not  rust.  Mckel  plating  has 
been  proved  to  be  not  so  valuable  as  was  at  first  hoped,  for,  since  instru- 
ments which  are  subjected  to  constant  wear  have  soon  to  be  replated, 
they  would  prove  somewhat  expensive.  For  those  instruments  which 
are  but  rarely  used,  however,  nickel  plating  is  advantageous,  since  it 
protects  them  from  the  action  of  the  air. 

Instruments  made  of  aluminum  have  been  recommended,  but  they 
are  undesirable  for  the  following  reasons:  (1)  They  are  too  expensive; 
(3)  they  are  too  soft;  (3)  they  will  not  stand  repeated  sterilization. 

In  a  hospital,  one  nurse  or  assistant  should  be  given  the  full  charge 
of  the  instruments,  being  held  responsible  for  their  proper  sterilization 
and  preservation.     In  private  practice  the  surgeon  must  give  the  in- 

27 


28  A  TEXT-BOOK  OF   GYNECOLOGY 

struments  his  personal  attention;  and  even  in  hospitals  he  will  do  well 
to  watch  closely  the  assistant  to  whom  they  are  intrusted,  in  order  to 
be  sure  that  the  constant  careful  attention  which  is  absolutely  neces- 
sary is  being  paid  to  them. 

It  is  important  to  write  out  lists  of  instruments  that  are  used  in 
the  different  operations  and  to  keep  them  where  they  can  be  easily 
consulted  on  each  operation  day,  so  that  none  which  will  be  needed 
will  be  forgotten.  Those  lists  should  be  divided  into  two  parts,  the 
first  containing  instruments  which  are  sure  to  be  required;  the  second, 
those  that  may  possibly  be  needed  under  certain  circumstances;  they 
should  therefore  be  prepared,  although  they  may  be  set  aside  until 
they  are  called  for.  (For  special  lists  of  instruments,  see  the  different 
operations.) 


CHAPTER    VI 
DIAGNOSIS 

Definition  and  scope — Indications  and  contraindications  for  vaginal  examination — 
The  gynecological  examination :  Physical ;  the  armamentarium ;  the  examina- 
tion itself ;  inspection  of  the  external  genitals ;  digital  examination ;  bimanual 
examination;  rectal  exploration ;  examination  under  anaesthesia;  examination 
of  the  abdomen ;  regions  of  the  abdomen ;  instrumental  examination  by  (a)  the 
speculum,  (b)  the  sound,  (c)  the  dilator,  (d)  the  curette,  (e)  the  aspirator — 
Examination  of  the  secretions — Urine — Faeces — Menstrual  discharge — The 
nervous  system. 

The  diagnosis  of  a  gynecologic  case  consists  in  determining  the 
character  and  location  not  only  of  the  local  disease,  but  of  any  asso- 
ciated pathologic  states.  The  destructive  character  of  many  of  the 
infectious  diseases  and  of  both  the  benign  and  malignant  neoplasms 
in  women,  and  the  essentially  insidious  onset  of  many  of  these  condi- 
tions, render  prompt  examination  and  early  diagnosis  necessary  for  the 
welfare  of  the  patient.  This  fact  will  be  emphasized  in  discussing  the 
diagnosis  of  individual  diseases.  To  the  end  that  diagnosis  may  be 
made  early,  it  is  the  duty  of  the  practitioner  to  impress  upon  his  cli- 
entele the  importance  of  this  step,  and  that  it  may  be  made  accurately, 
it  is  essential  that  he  should  take  the  broadest  possible  survey  of  the 
patient  and  make  the  most  critical  investigation  of  even  suggestive 
departures  from  health.  It  is  better,  in  an  effort  to  avoid  a  narrow 
investigation  of  simply  the  conditions  complained  of,  to  leave  the 
examination  of  the  genital  state  until  all  essential  facts  in  the  patient's 
general  history  have  been  ascertained.  To  this  end  systematic  inquiry 
should  first  be  made  relative  to  the  patient's  age,  hereditary  influences, 
menstrual  and  marital  histories,  previous  diseases,  and  present  com- 
plaints. A^Tiile  these  interrogatories  are  being  made  and  answered  the 
physician  should  cultivate  the  habit  of  carefully  noting  the  patient's 
appearance,  with  special  reference  to  her  nutrition,  her  nerve  poise, 
and  her  temperamental  characteristics.  The  pulse  should  be  counted, 
the  tongue  should  be  inspected;  in  short,  a  general  survey  of  the  pa- 
tient sbould  be  made  before  strictly  pelvic  conditions  are  either  in- 
quired into  or  examined.  All  of  the  facts  thus  gleaned  should  be  re- 
corded and  held  in  mind  during  the  progress  of  the  physical  examina- 
tion, which  should  embrace  the  following  steps: 

(a)  The  gynecological  examination,  including,  if  necessary,  an  ex- 
ploration of  the  bladder  and  rectum  and  inspection  and  palpation  of 
the  abdomen. 

29 


30  A   TEXT-BOOK   OF   GYNECOLOGY 

(&)  Special  physical  examination,  including,  according  to  the  indi- 
cations of  the  case,  inspection  of  the  throat  and  upper  air-passages, 
percussion  and  auscultation  of  the  heart  and  lungs,  ophthalmoscopic 
examination,  etc. 

(c)  Examination  of  the  secretions — e.  g.,  the  urine,  faeces,  menstrual 
flow,  and  perspiration. 

(d)  Examination  of  the  blood. 

(e)  Examination  of  the  nervous  system,  with  special  reference  to 
the  determination  of  sensory  and  motor  disturbances. 

Indications  and  Contraindications  for  Vaginal  Examination. — In 
cases  of  girls  and  unmarried  women  a  vaginal  examination,  either  digi- 
tal or  instrumental,  should  be  undertaken  only  in  the  presence  of  posi- 
tive indications.  Youth  and  virginity  should  always  be  looked  upon 
as  contraindications  for  such  an  exploration,  unless  in  the  presence  of 
more  than  counterbalancing  reasons:  such,  for  instance,  as  the  pres- 
ence of  all  the  menstrual  phenomena,  the  flow  excepted,  suggesting 
the  possible  retention  of  the  menstrual  fluid;  or  in  the  presence  of 
an  offensive  discharge  associated  with  remoter  pelvic  symptoms;  or  to 
investigate  the  origin  of  a  persistent  hemorrhage.  There  are  numerous 
other  conditions  the  importance  of  which  will  occur  to  the  practitioner. 
It  should  be  set  down  as  a  rule  to  which  there  are  but  few  exceptions, 
that  the  examination  of  young  girls  in  particular,  and  of  many  unmar- 
ried women  of  the  nervous  type,  should  be  undertaken  only  under  anaes- 
thesia. In  this  way  alone  can  they  be  protected  from  a  serious  moral 
shock  and  more  or  less  physical  discomfort.  AAHien  the  examination 
is  being  made  great  care  should  be  taken  to  preserve  as  far  as  possible 
all  virginal  conditions;  but  this  consideration  ought  not  to  obtain  to 
the  point  of  defeating  thoroughness  of  exploration  in  the  presence  of 
manifest  necessity. 

In  married  women  less  hesitancy  should  be  manifested  in  under- 
taking an  examination,  although  even  in  such  cases  it  should  not  be 
done  for  trivial  reasons.  When,  however,  there  are  either  pudendal, 
vaginal,  or  high  pelvic  symptoms  of  an  obscure  character  and  suffi- 
ciently severe  to  justify  treatment  at  all,  the  practitioner  owes  it  both 
to  himself  and  his  patient  to  insist  upon  an  examination.  Any  failure 
to  take  this  stand  is  liable  to  be  disastrous  to  both  parties. 

In  women  past  the  menopause,  all  symptoms  of  a  pelvic  character 
should  be  regarded  with  suspicion  and  inquired  into  with  promptness 
and  precision.  This  is  especially  true  in  the  presence  of  hemorrhage 
at  or  about  the  period  of  the  change  of  life — a  symptom  which  is 
nearly  always  an  evidence  of  malignant  disease.     (See  Menopause.) 

The  Gynecological  Examination. — It  is  as  important  in  all  gyneco- 
logical procedures  to  establish  accuracy  of  diagnosis  as  in  any  other 
department  of  medicine.  The  responsibility  of  the  gynecologist  is  not 
second  in  this  respect  to  that  of  his  confreres  in  the  other  branches  of 
medical  or  surgical  science. 

The  foundation  of  correct  diagnosis  lies  in  the  thorouffhness  of  the 


DIAGNOSIS  31 

examination,  and  to  this  end  every  known  means  must  be  invoked  in 
discovering  the  real  seat  of  the  malady  and  the  character  of  its  possible 
complications. 

At  the  initial  consultation  a  complete  history  of  the  patient's  con- 
dition should  be  obtained  and  accurately  recorded.  For  this  purpose 
it  will  be  convenient  to  have  a  book  so  bound  as  to  contain  one  hundred 
histories,  and  so  ruled  and  spaced  that  additional  entries  may  be  made 
at  subsequent  dates.  It  is  a  good  plan  to  have  the  history  blanks 
printed  in  sheets  that  may  be  filed  temporarily  and  be  bound  after  an 
adequate  number  have  been  filled. 

The  form  of  the  blank  can  be  devised  by  each  physician  according 
to  his  own  preferences,  hence  it  is  only  necessary  here  to  call  attention 
to  the  essential  points  of  the  record.  These  are — after  entering  the 
name,  age,  social  condition,  address,  and  other  preliminary  data — to 
record  the  family  history  as  bearing  on  heredity;  the  menstrual  history; 
the  number  of  children  borne  and  the  character  of  the  labours;  mis- 
carriages and  their  sequelae;  condition  of  bowels  and  bladder  as  to  func- 
tion; all  pelvic  phenomena  that  are  abnormal;  and,  finally,  every  fact 
pertaining  to  the  special  condition  for  which  the  consultation  is  sought. 
After  the  physical  examination  has  been  made,  all  lesions,  growths,  or 
abnormities  should  be  carefully  entered,  and  the  treatment  advised  or 
instituted,  set  forth  in  detail.  Each  physician,  as  he  becomes  impressed 
with  the  value  that  attaches  to  accuracy,  will  record  all  data  shown  by 
experience  to  be  important.  The  foregoing  are  merely  suggestive,  and 
are,  moreover,  such  as  may  not,  in  any  case,  be  omitted. 

Physical  Examination. — After  having  made  and  recorded  an  oral 
examination  of  the  patient,  the  next  step  involves  a  physical  investiga- 
tion by  inspection,  palpation,  and  pelvic  exploration.  The  events 
under  consideration  in  these  pages  are  made  applicable  to  office  con- 
sultations, hence  details  are  given  adapted  to  that  environment.  Suit- 
able rooms  are  requisite,  and  should  number  three  or  more,  en  suite — 
one  a  reception  room,  another  a  consulting  room,  and  a  third  solely 
used  for  the  examination.  In  this  last  there  should  be  running  water, 
hot  and  cold,  and  a  toilet  room  adjoining  is  well-nigh  a  necessity.  The 
examining  and  toilet  rooms  should  be  presided  over  by  a  comely  woman, 
trained  as  an  office  assistant.  She  need  not  necessarily  be  a  nurse,  but 
she  should  be  a  trustworthy  woman  competent  to  hold  a  speculum 
and  intelligent  in  all  that  pertains  to  gynecological  work. 

The  armamentarium  should  consist  of  a  table,  specula,  dressing 
forceps  and  tenacula,  douche  apparatus,  absorbent  cotton  and  antisep- 
tic wool,  sounds  and  applicators,  lubricant,  protective  or  pad,  sheet, 
and  gown. 

The  table  should  be  strong  and  should  stand  solidly  on  its  four 
logs.  It  should  be  capable  of  extension  to  enable  the  patient  to  lie 
in  the  horizontal  position,  reasons  for  which  will  be  considered  pres- 
(inily.  II,  need  not  necessarily  be  an  expensive  or  complicated  affair, 
but  should  be  equipped  with  foot  rests,  a  thin  mattress,  and  pillows. 


32  A  TEXT-BOOK  OP   GYNECOLOGY 

An  assortment  of  Sims's  specula  are  essential,  and  one  or  two  good 
bivalves  will  be  convenient. 

Every  successful  g3^necologist  knows  the  value  of  the  Sims  specu- 
lum, and  every  one  Avho  expects  to  practise  the  specialty  must  of  neces- 
sity make  himself  familiar  with  its  uses.  The  objection  often  made  to 
it  is  that  a  competent  person  is  required  to  hold  it.  If  the  beginner 
can  not  emjiloy  such  a  person,  then  he  must  provide  himself  with  one 
of  the  so-called  self -retaining  Sims  instruments.  Potter  prefers  the 
Emmet  self -retaining  attachment  for  this  purpose.  It  is  the  simplest 
and  can  be  held  easily  by  the  patient,  who  will  grasp  a  piece  of  rubber 
tubing  passed  through  the  f  enestrum  of  the  buttock  blade. 

Sounds  and  applicators  are  included  in  the  office  outfit,  but  it  is 
proper  to  remark  that  they  seldom  will  be  needed.  The  indiscriminate 
use  of  the  sound  has  proved  harmful  to  many  women,  and  should 
never  be  used  by  unskilful  hands.  Nevertheless  it  will  occasionally 
be  serviceable  as  an  aid  to  diagnosis,  hence  is  included  in  the  list. 
Applicators,  too,  will  rarely  be  employed.  We  need  not  enter  into  a 
discussion  of  the  propriety  of  topical  applications  to  the  endometrium, 
but  it  will  suffice  to  say  that  as  a  routine  it  is  of  doubtful  propriety. 
Occasionally,  however,  such  treatment  is  needful,  hence  the  instru- 
ments must  be  at  hand. 

The  selection  of  a  proper  lubricant  is  a  matter  of  considerable  im- 
portance. Vaseline  is  in  common  use,  but  it  is  not  easily  removed 
from  the  hands.  Dudley  (Diseases  of  Women,  second  edition.  Lea 
Brothers  &  Co.,  1900)  prefers  glycerine,  which  is  cleanly,  sterile,  but 
expensive.  Some  are  partial  to  glymol,  certainly  an  excellent  agent. 
Potter  recommends  alboline  in  collapsible  tubes,  which  is  thus  kept 
germ  free,  is  cheap,  and  efficient. 

The  so-called  Kelly  pad,  really  a  device  of  Joseph  Price,  is  a  con- 
venient protective,  but  it,  too,  is  expensive,  and  besides  is  difficult  to 
keep  clean.  A  piece  of  rubber  sheeting  will  answer  every  purpose,  pro- 
vided that  it  is  rolled  at  the  sides  and  back  to  prevent  backfiow  of 
water. 

A  douche  apparatus  should  be  at  command  for  all  office  examina- 
tions or  treatment.  It  should  consist  of  a  reservoir  that  will  hold  at 
least  a  gallon  of  sterilized  water,  with  rubber  tubing  attached  to  a 
vaginal  douche  nozzle  with  backfiow  arrangement,  and  the  tubing 
should  be  equipped  with  a  gate  or  cut-off.  Before  examination  the 
woman  should  be  divested  of  unnecessary  clothing,  such  as  corsets  and 
superffiious  skirts,  then  placed  upon  the  table  in  the  dorsal  posture, 
with  feet  in  the  foot  rests,  and  the  pad  or  protective  properly  adjusted 
to  prevent  Avetting  or  soiling  the  clothing.  After  covering  her  with 
a  sheet,  tlie  douche  may  be  administered.  This  should  consist  of  an 
appropriate  quantity  of  sterilized  water  at  a  temperature  of  about  115° 
F.  If  there  is  suspicion  of  infection,  the  douche  should  be  rendered 
antiseptic  by  the  addition  of  bichloride  of  mercury  sufficient  to  make 
a  solution  of  1  to  2,000. 

\ 


DIAGNOSIS 


53 


Fig.  1. — "  The  woman  is  now  placed  upon  the  table, 
usually  in  the  dorsal  position." — Potter. 


The  Examination. — The  preparation  of  the  patient  may  be  made 
by  the  office  assistant,  who,  as  we  have  said,  should  be  a  competent 

woman.  She  shouhl  ar- 
range the  clothing  of  the 
patient,  administer  the 
donche,  and,  if  need  be, 
give  an  enema  to  unload 
the  rectum.  This  latter 
is  important  if  there  is 
constipation,  as  a  distend- 
ed lower  bowel  may  mis- 
lead in  diagnosis.  Such  a 
condition  not  only  dis- 
places the  pelvic  viscera, 
but  it  may  be  mistaken 
for  a  tumour,  new  growth, 
or  retro  verted  uterus.  Af- 
ter these  preliminaries  the 
patient  is  ready  for  the  examination  proper,  which,  it  is  almost  needless 
to  add,  in  these  days  of  asepsis,  should  be  conducted  with  the  utmost 
aseptic  care. 

The  examiner  himself  should  prepare  his  hands  as  carefully  as  if 
he  were  about  to  conduct  an  abdominal  section  or  other  important 
surgical  operation.  His  lavatory  should  be  supplied  with  the  best  of 
soap.  A  number  of  nail  brushes,  too,  should  be  at  hand,  and  of  these 
there  is  none  better,  or  indeed  so  good,  as  those  made  of  vegetable 
fibre.    They  are  cheap,  durable,  and  can  be  kept  clean. 

We  have  already  alluded  to  the  administration  of  the  douche,  which 
should  invariably  precede  the  examination  unless  for  some  special  rea- 
son it  becomes  necessary  to  inspect  the  uterine,  vaginal,  and  vulvar 
fields,  to  study  their 
secretions  or  exudates 
with  a  view  to  deter- 
mine their  character, 
in  the  expectation  that 
they  may  furnish  an 
important  aid  to  diag- 
nosis. But  when  it 
is  used,  particular  care 
must  be  paid  at  the 
conclusion  of  the  ex- 
amination to  the  dis- 
infection of  the  douche  nozzle  as  well  as  of  the  hands  of  the  physician 
and  assistant  and  of  all  else  that  comes  in  contact  with  the  patient. 

With  these  preliminaries  the  woman  is  now  placed  upon  the  table, 
usually  in  the  dorsal  position  (I'ig.  1),  as  already  indicated;  or,  accord- 
ing to  tlio  r('f|iiir('iiiciiis  of  the  case  or  the  preference  of  the  operator, 
4 


Fig.  2.-" 


Or,  according  to  the  requirements  of  the  case, 
or  the  preferences  of  the  operator,  she  is  placed  in  the 
left  lateral  prone,  better  known  as  Sims's  posture." — 
Potter  (i)age  34). 


34: 


A   TEXT-BOOK  OF   GYNECOLOGY 


Fig.  3. 


-"  .  .  .  Which  is  better  appreciated  if  studied 
from  the  foot  of  the  table." — Potter. 


she  is  placed  in  the  left  lateral  prone,  better  known  as  Sims's,  posture 
(Fig.  2),  Adiich  is  better  appreciated  if  studied  from  the  foot  of  the  table 
(Fig.  3).  Occasionally  it  will  become  necessary  to  employ  the  knee- 
chest  posture  (Fig.  4),  and  sometimes  a  woman  should  be  examined 
while  she  is  standing  (Fig.  5). 

Upon  mounting  the  table,  the  woman  should  sit  upon  the  end  of  it, 
which  should  be  properly  covered  with  protective  and  aseptic  towels. 

A  pillow  should  be  provided 
for  her  head,  but,  as  she  is 
to  lie  flat  upon  her  back,  the 
shoulders  should  not  be  ele- 
vated by  the  pillow.  A  sheet 
or  other  proper  covering 
should  be  spread  upon  her 
lap  while  she  is  yet  sitting 
on  the  end  of  the  table.  She 
is  now  assisted  to  lie  down, 
the  nurse  taking  hold  of  her 
feet  and  placing  her  heels  in 
the  stirrups,  which  should 
be  placed  as  close  together  as  possible  and  which  have  been  drawn  out 
to  receive  them.  The  thighs  thus  become  flexed,  the  abdominal  mus- 
cles relaxed,  and  the  knees  widely  separated.  In  a  first  examination 
it  will  often  become  necessary  to  assure  the  patient  that  she  is  neither 
to  be  hurt  nor  exposed,  after  which  the  covering  may  be  parted  and 
adjusted  around  the  vulva,  which  is  ready  for  inspection. 

Inspection  of  the  External  Genitals. — It  becomes  necessary,  espe- 
cially with  a  strange  patient,  at  a  first  examination  to  inspect  the  vulvar 
field  with  care.  This  is  done,  not  only  for  diagnostic  reasons,  but  for 
safety.  A  physician  may  become  infected  from  a  venereal  sore,  even 
on  the  person  of  an  inno- 
cent woman,  unless  the 
presence  of  such  a  le- 
sion is  detected  before- 
hand. To  be  forewarned 
is  to  be  forearmed.  In 
the  investigation  of  such 
a  case,  abrasions  of  the 
hand,  and  especially  of  the 
examining  finger,  should 
be  painted  with  collodion. 
Having  determined 
the  nature  of  the  secre- 
tions of  the  parts,  and 
having  carefully  inspected  tlie  hymeneal  orifice,  noting  whether  the 
hymen  has  been  ruptured,  the  examiner  should  next  look  carefully 
for  the  evidences  of  parturition — such  as  lacerations,  cicatrices,  and  the 


Fig.  4.- 


-"  Occasionally  it  will  become  necessary  to  em- 
ploy the  knee-chest  posture." — Potter. 


DIAGNOSIS 


like — and  then  he  may  look  for  tumovirs,  urethral  caruncles,  vulvitis, 
urethritis,  eruptions,  ulcerations,  cj^stocele,  rectocele,  inflammations  of 
Bartholin's  and  Skene's  glands,  osdema,  and  pruritus.  The  rectum 
should  be  explored  with  reference  to  hemorrhoids,  fissure,  fistula  in  ano, 
pinworms,  and  any  anomaly  of  anatomic  configuration.  The  clitoris 
should  be  examined  with  reference  to  any  enlargement  or  an  adherent 
prepuce.  The  vulvar  orifice,  if  capacious  or  gaping,  gives  token  at  least 
of  marital  relations,  whereas  the  virgin  vulvar  orifice  is  small,  com- 
pact, with  a  more  or  less  perfect  hymen.  The  absence,  however,  of  the 
hymen  is  not  considered  evidence  of  unchastity — a  fact  that  should 
always  be  kept  uppermost  in  the  mind  of  the  gynecologist,  especially 
in  the  commencement  of  his  practice. 
The  condition  of  the  labia  minora  should 
also  be  noted.  When  these  are  long,  flab- 
by, and  pendulous  in  contour,  it  is  prob- 
able that  the  woman  is  a  masturbator. 
This  condition  of  the  minor  labia,  it  is 
quite  true,  might  arise  from  other  causes, 
but  this  is  the  most  probable  explanation 
of  it. 

While  inspection  is  usually  limited  to 
the  region  and  for  the  purposes  named,  it 
may  be  carried  upward  to  include  the 
surface  of  the  abdomen,  whereby  enlarge- 
ment or  imperfection  of  contour  may  be 
discovered.  Inspection  of  the  interior  of 
the  vagina  through  the  speculum,  and  of 
the  rectum  by  a  similar  instrument,  does 
not  come  within  the  limit  of  this  section, 
but  will  be  described  under  its  appropriate 
head. 

Digital  Examination. — By  far  the  most 
important  method  of  investigation  is  the 
examination  by  the  fingers  and  hands. 
The  tactile  sense  is  so  acute,  and  may  be 
so  highly  educated,  as  to  supersede  or  take  the  place  of  every  other 
method,  provided  one  were  limited  to  a  single  means  of  obtaining 
information.  It  becomes  of  the  first  importance,  therefore,  that 
it  shall  be  employed  intelligently,  systematically,  and  thoroughly. 
We  shall  not  enter  into  an  argument  as  to  whether  the  right  or 
left  index  finger  is  the  better  for  this  investigation,  but  shall  con- 
tent ourselves  with  saying  that  while  the  specialist  will  frequently 
prefer  the  left,  and  most  of  such  at  least  will  be  ambidextrous,  the 
general  practitioner  will  usually  employ  his  right  finger  or  fingers  for 
the  digital  examination.  An  advantage  in  using  the  left  finger  is  that 
it  leaves  the  right  band  free  for  instrumental  use  and  for  bimanual 
examination.     Again,   it  preserves  the  right  hand  from  the  danger 


Fig.  5.—".  .  .  Sometimes  a  woman 
should  be  examined  while  she 
is  standing." — Pottee  (page  34). 


36  A   TEXT-BOOK  OP   GYNECOLOGY 

of  becoming  an  infection  carrier,  which  is  perhaps  a  matter  of  con- 
siderable moment  in  dispensary  or  hospital  work.  Sometimes  it  will 
be  useful  to  employ  two  fingers  in  the  investigation,  but  this  will  be 
rather  the  exception  than  the  rule,  limited  to  the  capacious  vagina 
and  the  short  index  finger.  Two  fingers  in  a  narrow  vagina  are,  to  say 
the  least,  painful;  but,  as  the  index  finger  is  sometimes  short  and  the 
diagnostic  reach  can  be  increased  perhaps  half  an  inch  by  the  con- 
joined use  of  the  index  and  ring  fingers,  this  expedient  occasionally 
becomes  not  only  justifiable  but  useful. 

There  is  nothing  that  indicates  greater  gynecological  skill  than 
the  tactful  employment  of  the  digital  examination.  The  clumsy,  hasty, 
and  rough  manner,  in  which  it  is  sometimes  used,  is  to  be  strongly 
condemned.  On  the  other  hand,  it  should  be  employed  with  the  great- 
est delicacy,  but  at  the  same  time  with  thoroughness,  precision,  and 
aptitude.  Every  gynecologist  should  avail  himself  of  every  oppor- 
tunity to  educate  his  finger  tips;  indeed,  they  should  be  brought  to  that 
degree  of  tactile  perfection  that  a  reasonable  degree  of  accuracy  in 
diagnosis  can  be  obtained,  in  the  majority  of  cases,  without  an  appeal 
to  instrumental  aid.  The  digital  examination  becomes  available  and 
applicable  in  the  horizontal,  dorso-sacral,  latero-prone,  genu-pectoral, 
and  standing,  postures.  But  its  chief  application  is  in  the  dorsal  or 
dorso-sacral  postures.  Finally,  the  index  finger  occasionally  becomes  of 
great  usefulness  in  everting  the  anus  by  pressure  through  the  vagina 
upon  its  posterior  wall.  In  this  manner  the  examiner  will  often  detect 
with  ease  and  precision  rectal  or  anal  faults  that  otherwise  might  re- 
main obscure. 

It  remains  for  us  to  give  the  technique  of  the  digital  examination. 
To  begin  with,  let  us  repeat,  the  toilet  of  the  hands,  and  especially  of 
the  index  finger  to  be  employed,  should  be  most  carefully  made.  Thor- 
ough washing  with  soap  and  warm  water  and  scrubbing  with  the  nail 
brush  should  precede  the  lubrication.  Then  the  finger  tip,  palmar 
surface  dowuAvard,  should  be  carefully  passed  into  the  vagina  against 
its  posterior  wall,  the  fingers  of  the  other  hand  being  used  to  separate 
the  labia  and  to  slightly  distend  the  vulvar  orifice.  In  this  manner 
it  will  note,  first,  the  condition  of  the  perineum,  its  rigidity  or  laxness, 
its  integrity  or  imperfectness;  secondly,  the  condition  of  the  rectum, 
whether  it  contains  f^ces  or  is  empty;  thirdly,  the  relation  of  the  coccyx 
to  the  pelvic  outlet;  and  fourthly,  the  capaciousness  or  narrowness  of 
the  vagina.  Turning  now  the  finger  upward  and  passing  from  side  to 
side  along  the  vagina,  its  lateral  surfaces  are  explored,  until  finally 
the  cervix  uteri  is  reached.  Here  is  an  important  field  for  investi- 
gation. If  the  cervix  is  soft,  like  the  lips,  a  suspicion  of  preg- 
nancy will  arise;  if  firm  or  hard,  like  the  nose,  such  suspicion  will 
be  dispelled.  The  cervix  and  os  must  now  be  carefully  examined  with 
reference  to  size  and  form  and  direction  of  the  cervix,  and  the  pres- 
ence or  absence  of  lacerations  or  new  growths  in  the  os.  The  im- 
portance of  thoroughness  with  reference  to  this  portion  of  the  exami- 


DIAGNOSIS 


3Y 


nation  is  to  be  insisted  upon,  and  an  educated  finger  tip  is  essential 
to  its  completeness. 

Bimanual  Examination. — A  great  advance  in  the  diagnosis  of  pel- 
vic diseases  was  signalized  by  the  introduction  of  the  bimanual  method 
of  investigation  (Fig.  6).  The  term  may  be  defined  as  the  examina- 
tion of  the  pelvic  contents  by  the  two  hands,  the  index  finger  of 
one  being  in  the  vagina  and  the  other  placed  on  the  abdomen  above 
and  beyond  the  pubes  with  which  to  make  downward  pressure.  The 
finger  within  the  vagina  lifts  up  the  organ  or  organs,  and  the  finger  tip 
of  the  other  hand  pressing  downward  upon  the  relaxed  abdominal  walls 


Fig.  6. — "  A  great  advance  in  the  diagnosis  of  pelvic  disease  was  signalized  by  the  introduc- 
tion of  the  bimanual  method  of  examination." — Potter. 


engages  it  or  them  between  the  two.  Beginning  first  with  the  bladder, 
its  sensitiveness,  distention,  or  emptiness,  is  noted.  Passing  upward 
to  the  uterus,  its  size,  condition  as  to  firmness  or  softness,  and  its  posi- 
tion, whether  in  anteflexion,  retroflexion,  or  prolapsus,  is  determined. 
Here,  again,  the  first  question  upon  the  mind  is  that  of  possible  preg- 
nancy. If  in  the  digital  examination  a  soft  cervix  has  been  felt,  the 
inquiry  as  to  pregnancy  must  be  pursued  bimanually,  and  if  it  is 
learned  that  the  uterus  is  enlarged  and  has  floating  contents  the  sus- 
picion will  b(!  coufirrnofl,  and  further  examination  should  be  postponed 
until  1lif;  f|ncstion  is  (lelofrriincd.     It  is  iinjKjrtant  to  deal  with  this  sub- 


38  A  TEXT-BOOK  OF   GYNECOLOGY 

ject  first,  because,  in  case  23regnancy  exists,  it  stands  in  the  way  of  any 
further  23elvic  exploration  lest  abortion  be  induced..  An  exception  to 
this  rule  would  be  when  tumours  or  new  growths  coexisted  with  sup- 
posed pregnancy  or  complicated  each  other  in  an  already  diagnosticated 
condition.  Then,  if  there  is  some  technical  point  to  determine,  the 
bimanual  examination  may  be  cautiously  further  pursued. 

Displacements  of  the  uterus  are  most  easily  and  certainly  diag- 
nosticated by  means  of  the  bimanual  examination.  The  normal  posi- 
tion of  the  uterus,  it  will  be  remembered,  is  one  of  moderate  ante- 
flexion, in  which  a  line  drawn  through  its  long  axis  appears  at  the 
umbilicus;  with  the  fundus,  however,  lying  farther  forward,  compress- 
ing the  bladder  and  impinging  on  the  pubes,  the  uterine  body  will  be 
easily  engaged  and  mapped  out  between  the  two  hands.  It  will,  how- 
ever, require  some  experience  to  distinguish  between  anteversion  and 
anteflexion — all  of  which  will  be  properly  set  forth  by  another  writer 
under  its  appropriate  head.  Retrodisplacement  of  the  uterus  may  also 
be  determined  by  feeling  the  fundus  resting  against  the  rectum  in  the 
sacral  excavation,  and  by  its  absence  from  its  appointed  place  as  ascer- 
tained by  pressure  of  the  external  hand.  The  cervix,  too,  in  retrover- 
sion, will  be  carried  upward  and  forward  toward  the  pubic  arch,  thus 
resting  the  entire  organ  horizontally  across  the  pelvis  at  right  angles 
to  the  normal  direction  of  the  vagina.  Here,  again,  some  nicety  of 
touch,  which  a  little  experience  may  soon  acquire,  is  required  to  de- 
termine between  retroversion  and  retroflexion.  Prolapse  of  the  uterus 
is  more  easily  determined,  since  the  index  finger  will  come  in  contact 
with  the  cervix  just  within  the  vulvar  orifice,  or  a  little  higher  up, 
according  to  its  degree.  Procidentia  will  readily  be  discovered  upon 
insiDCction,  since  the  organ  in  Avhole  or  in  part  protrudes  from  the 
vagina. 

One  of  the  most  important  functions  of  the  bimanual  is  to  ascer- 
tain the  condition  of  the  tubes  and  ovaries.  An  experienced  examiner 
will  readily  discover  whether  the  tubes  are  enlarged,  pulpy,  and  soft  or 
hardened,  and  whether  the  ovaries  are  unduly  tender  and  sensitive, 
enlarged  or  atrophied,  displaced,  or  the  seat  of  new  growths.  An  en- 
larged pulpy  tube,  sausagelike  in  shape,  is  suggestive  of  hydrosalpinx 
or  pyosalpinx.  At  any  rate,  it  means  a  diseased  condition,  which  an 
accurate  history  combined  with  careful  bimanual  palpation  will  usually 
distinguish.  The  broad  ligaments  should  also  be  carefully  inter- 
rogated as  to  whether  new  growths  lurk  within  their  folds  and  if  they 
properly  support  the  uterus  and  adnexa.  Adhesions,  too,  should  be 
sought  for,  and  if  found,  will  of  necessity  influence  further  investiga- 
tion and  treatment.  If  the  uterus  and  its  appendages  are  tender,  bound 
down  by  adhesions,  or  if  there  is  an  abscess  or  pus  tube,  great  caution 
must  be  exercised  in  ^jursuing  further  investigation.  It  would  be  in- 
excusable to  rupture  such  a  pus  container,  or  to  set  up  further  inflam- 
matory processes  by  the  use  of  force  in  the  bimanual,  or  through  a  re- 
sort to  instrumentation. 


'       DIAGNOSIS  39 

It  will  be  readily  understood  from  the  foregoing  that  the  proper 
exercise  of  the  bimanual  in  order  to  attain  its  greatest  possibilities  re- 
quires an  experience  that  only  long  practice  can  give;  hence,  the  be- 
ginner should  never  miss  the  opportunity  of  employing  it  under  the 
supervision  of  a  competent  instructor.  Only  in  this  way  can  he  learn 
either  to  bring  the  organs  properly  within  reach,  or  to  appreciate  what 
he  feels  between  his  hands. 

At  the  outset  he  will  often  be  foiled  in  his  efforts  by  the  nervous- 
ness of  the  patient;  this  he  must  overcome  by  his  tact  and  gentleness, 
always  giving  the  imjoression  that  he  is  thoroughly  at  home  in  his 
work.  If  he  betrays  his  inexperience  by  suddenness  of  movement,  inex- 
actitude of  touch,  or  other  evidences  of  the  novitiate,  his  usefulness 
will  be  limited  or  destroj^ed.  Complete  muscular  relaxation  on  the 
part  of  the  jjatient  must  be  obtained,  and  great  self-possession  by  the 
examiner  must  exist.  These  two  factors  are  conditions  precedent  to 
success. 

It  is  well  to  remember  in  pursuing  the  bimanual  method,  espe- 
cially when  it  becomes  necessary  to  make  upward  pressure  upon  the 
vulvar  orifice  in  order  to  reach  high  up  in  the  pelvic  cavity,  that  some- 
times sensitive  or  jDassionate  women  may  be  incited  to  sexual  orgasm 
from  irritation  of  the  clitoris;  hence,  contact  with  that  organ  should 
be  avoided  as  far  as  possible.  It  is  probable  that  the  aggregate  number 
of  such  ]3atients  is  very  inconsiderable,  because  illness,  and  especially 
disorders  of  the  pelvic  organs,  diminish  the  tendency  to  sexual  excite- 
ment arising  from  physical  exploration  of  the  genital  tract.  Its  possi- 
bility, however,  should  not  be  forgotten. 

To  recapitulate,  the  information  to  be  derived  from  the  bimanual 
method  of  examination  may  be  grouped  as  follows: 

First,  capacity,  rigidity,  and  tonicity,  of  the  vagina. 

Secondly,  as  to  pregnancy,  pro  or  con. 

Thirdly,  the  condition  of  the  bladder  and  its  relation  to  the  other 
pelvic  organs. 

Fourthly,  the  uterus,  its  size,  position,  presence  or  absence  of 
tumours  within  its  walls,  and  the  condition  of  the  cervix  as  to  integrity 
or  lacerations. 

Fifthly,  the  status  of  the  tubes  and  ovaries  as  to  size,  location,  and 
relationship  to  neighbouring  parts. 

Sixthly,  the  condition  of  the  rectum  as  to  faecal  impaction  or  disease 
of  any  kind,  such  as  fistula,  fissure,  cancer,  or  hemorrhoids. 

Seventhly,  as  to  the  presence  of  any  abdominal  or  pelvic  tumour, 
new  growth,  extra-uterine  pregnancy,  or  any  abnormal  condition  not 
embraced  in  the  foregoing  classification. 

Finally,  it  may  be  remarked  that  in  the  case  of  tumours  the  biman- 
ual affords  opportunity  to  distinguish  between  cystic  and  solid  growths, 
and,  to  a  certain  extent,  between  benign  and  malignant  neoplasms. 

Rectal  Exploration. — It  remains  for  us  to  describe  examination  by 
the  rectum,  which  oftentimes  becomes  an  important  adjunct  to  the 


40  A   TEXT-BOOK   OF   GYNECOLOGY 

examination.  The  index  finger  in  the  rectum  will  sometimes  serve  to 
clear  up  a  doubt  or  detect  a  hitherto  undiscovered  condition.  It  will 
help  to  diagnosticate  a  retroverted  womb  or  to  distinguish  between  that 
displacement  and  a  post-nuiral  fibroid  growth.  Again,  it  will  serve 
to  locate  a  hitherto  undiscovered  ovary  occupying  Douglas's  pouch. 
Still  again,  examination  per  rectum  may  detect  disease  in  that  organ 
which  will  explain  symjDtoms  that  otherwise  would  have  been  misun- 
derstood. In  all  cases  in  which  careful  vaginal  bimanual  fails  to  dis- 
cover disorder  adequate  to  explain  symptoms  or  to  suggest  a  diagnosis, 
rectal  exploration  should  be  made.  This  procedure  is  often  disagree- 
able, if  not  painful,  to  the  patient,  hence,  must  be  instituted  with  great 
delicacy  and  only  after  thorough  lubrication  of  the  examining  finger 
as  well  as  the  anal  orifice.  External  hemorrhoids,  even  if  inactive,  will 
further  emphasize  the  importance  of  careful  preliminaries  to  the  ex- 
ploration.    (See  Examination  of  the  Rectum.) 

Examination  under  Angesthesia. — Finall}^,  when  all  the  ordinary 
means  fail  to  overcome  the  nervousness  of  the  patient,  the  rigidity  of 
the  abdominal  muscles,  or  other  hindrances  to  the  thorough  and  intel- 
ligent employment  of  the  bimanual  method  of  examination,  anaesthesia 
may  be  appealed  to;  indeed,  with  the  full  consent  of  the  patient  and 
with  adequate  assistance  it  should  be  resorted  to  as  an  important  ele- 
ment in  leading  to  correct  diagnosis. 

Examination  by  this  means  should  be  carefully  conducted  with 
reference  both  to  its  advantages  and  its  dangers.  Its  advantages  con- 
sist in  overcoming  hypersensibilities,  botli  mental  and  physical,  and  in 
eliminating  involuntary  muscular  resistance  as  a  barrier  to  successful 
manipulation.  By  this  means  it  is  possible  to  explore  with  approximate 
accuracy  the  entire  peritoneal  surface  of  the  uterus,  both  anterior  and 
posterior.  The  ovaries  and  Fallopian  tubes  can  be  palpated;  the 
presence  and  absence  of  intrapelvic  tumours,  including  cysts,  myomata, 
nodes,  etc.,  can  be  determined.  The  presence  or  absence  of  adhesions 
can  often  be  decided.  The  disadvantages  of  anaesthesia  in  gyneco- 
logical examinations  centre  cliiefly  in  the  elimination  of  pain,  which  of 
itself  possesses  great  diagnostic  value,  and  is  also  a  safeguard  against 
injudicious  and  dangerous  manipulation.  It  may  be  laid  down  as  a 
rule,  therefore,  that  angesthesia  for  purposes  of  examination  is  dan- 
gerous in  the  presence  of  a  degree  of  sensibility  indicative  of  acute 
inflammation. 

Auscultation,  Percussion,  and  General  Palpation  of  the  Abdomen. — 
Of  diagnostic  measures,  auscultation,  percussion,  and  palpation,  can 
be  applied  to  the  recognition  and  diagnosis  of  pelvic  and  abdom- 
inal tumours,  inflammatory  residues,  and  diseases  of  the  appendi- 
csecal  region,  kidneys,  spleen,  liver,  and  gastro-intestinal  tract.  The 
method  of  applying  these  aids  to  diagnosis  will  be  readily  suggested  to 
the  examiner.  Palpation  of  the  kidney  becomes  important  in  relation 
to  the  diagnosis  of  diseases  of  that  organ,  and  occasionally,  also,  in 
distinguishing  between  abdominal  tumours  and  movable  and  so-called 


DIAGNOSIS 


41 


floating  kidney.  A  movable  kidney,  which  would  escape  the  casual  or 
indifferent  observer,  is  often  detected  by  a  careful  diagnostician.  Hy- 
dronejDhrosis  has  been  confounded  with  ovarian  and  other  cysts.  A 
detailed  description  of  the  diagnosis  of  kidney  diseases  is  foreign  to 
the  purpose  of  this  chapter,  and  the  reader  is  referred  to  the  section 
which  deals  with  that  subject.  In  examining  the  abdomen  it  is  highly 
important,  not  only  to  hold  in  mind  the  locus  of  each  of  its  contained 
organs,  but  to  have  an  accurate  conception  of  its  regional  arrangement. 
Regions  of  the  Abdomen. — It  has  been  customary  heretofore  to 
divide  the  abdomen  anteriorly  into  nine  different  regions  as  a  con- 
venient means  of  des- 
ignating either  the  lo- 
cation of  symptoms  or 
operations,  or  of  the 
presumably  underly- 
ing organs  and  struc- 
tures. This  division, 
however,  has  proved 
unsatisfactory,  because 
of  the  cumbersome- 
ness  of  its  terminol- 
ogy, the  narrowness 
of  the  areas  indicated, 
the  indefiniteness  of 
the  imaginary  lines  of 
division,  and  the  ana- 
tomical variations  in 
the  location  of  their 
supposed  underlying 
organs  and  structures. 
In  accordance  with 
the  suggestion  of  Pro- 
fessor Anderson  to 
the  Anatomical  Socie- 
ty of  Great  Britain 
(Buffalo  Medical  and 
Surgical  Jour.,  1893), 
these  objections  are 
best  obviated  by  divid- 
ing the  abdomen  into  four  regions.  This  is  done  by  running  a  line 
coincidently  with  the  linea  alba  from  the  symphysis  pubis  to  the  ensi- 
form  cartilage,  and  another  at  right  angles  to  this  at  the  level  of  the 
umbilicus  and  encircling  the  entire  body.  The  median  line  posteriorly 
is  indicated  by  the  spinal  column.  This  arrangement,  which  is  based 
upon  definite  landmarks,  and  divides  the  abdomen  into  four  quadrants 
(Fig.  7) — namely,  right  and  left,  upper  and  lower — will  be  observed  in 
the  following  pages. 


^^^B    RI&HT 
^^^H    QUADRANT 

LEFT     i 
UPPER         1 
QUADRANT      1 

f 

^^m       RIGHT 
^V             LOWER 
^m        QUADRANT 

LIJT 
LOWKR 
QUADRANT 

r 

1 

i 

RJ.H0PKIN3 

Fig.  7. — "  This  arrangement,  based  upon  detinite  landmarks, 
divides  the  abdomen  into  four  quadrants." — Keed. 


42 


A  TEXT-BOOK  OF   GYNECOLOGY 


Instrumental  Examination. — A  most  important  adjunct  to  methods 
of  diagnosis  is  furnished  in  the  marvellous  develoj)ment  of  mechanical 

instruments  and  appliances.  The  inge- 
nuity of  physicians  and  instrument 
makers  has  presented  to  the  gynecologist 
an  enormous  collection  from  which  to 
choose.  The  armamentarium,  however, 
should  be  simple,  and  such  instruments 
as  are  chosen  should  be  models  of  per- 
fection. It  should  never  be  forgotten, 
also,  that  instrumentation,  no  matter  how 
dexterously  applied,  can  never  be  made 
to  supplant  the  educated  hands  and  finger 
tips.  Instruments  at  most  are  supple- 
mentary aids  to  these.  We  may,  how- 
ever, enumerate  some  of  the  instruments 
which  are  considered  a  necessity  by  the 
g3^necologist.  These  are:  (1)  The  specu- 
lum, (2)  the  sound  or  probe,  (3)  the  dila- 
tor, (4)  the  curette,  (5)  the  cystoscope, 

(6)  the  aspirator  with  exploratory  needles, 

(7)  the  stethoscope,  (8)  the  uterine  dress- 
ing, forceps,  (9)  the  spatula  or  depressor, 
(10)  the  tenaculum,  (11)  the  volsella. 

The  Speculum  as  a  Means  of  Ex- 
amination. —  Since  Sims  gave  to  the 
profession  the  speculum  which  bears  his  name  the  practice  of  gyne- 
cology has  become  an  established  specialty.  Without  this  device  it  is 
doubtful  if  gynecology  could  have  been  enlarged,  broadened,  and  devel- 
oped into  the  importance  which  it  has  attained  at  the  present  day. 
Dr.  J.  Marion  Sims,  then  residing  in  the  city  of  Montgomery,  Ala.,  was 
engaged  between  the  years  1845  and  1849  in  the  study  of  the  opera- 
tive treatment  of  vesico-vaginal  fistula.  During  his  investigations  he 
accidentally  discovered  that  if  a  woman  Avas  placed  upon  her  knees 
and  chest,  upon  separating  the  labia  the  air  would  enter  the  vagina  and 
distend  it  to  its  full  capacity.  Wliat  was  needed  was  an  instrument  to 
retract  the  perineum.  This  he  supplied  first  with  a  spoon  handle  bent 
to  the  appropriate  shape,  and  afterward,  as  the  product  of  evolution, 
came  the  present  speculum,  which  universally  bears  the  name  of  Sims 
(Fig.  8).  In  the  further  pursuit  of  his  investigations,  and  for  the  ap- 
propriate use  of  his  speculum,  a  less  trying  posture  was  needed  than  the 
knee-chest.  This  led  to  further  experimentation  from  which  was 
evolved  the  semiprone,  or  Sims's,  position.  It  is  sometimes  called  the 
latero-prone  posture,  but,  by  whatever  name  it  is  known,  its  discovery 
and  practical  application  are  due  to  Marion  Sims.  The  Sims  speculum 
and  the  Sims  position  form  the  basis  of  the  science  of  gynecology  as  at 
present  understood  and  practised.     Whoever,  then,  would  attain  suc- 


FiG.  8. — ".  .  .  Speculum,  whicli  uni- 
versally bears  the  name  of  Siras." 
— Potter. 


DIAGNOSIS 


43 


cess  in  the  art,  must  not  only  familiarize  himself  with  the  principles  of 
this  instrument  and  its  correlative  posture,  but  he  must  acqure  deftness 
in  their  practical  application  to  the  patients  who  consult  him. 

The  beginner,  therefore,  should  address  himself  to  the  mastery  of 
the  use  of  the  Sims  speculum  in  the  semiprone  or  Sims  posture. 
The  principles  are  simple  and  the  obstacles  to  be  overcome  are  few. 
It  is  a  mistake  to  suppose  that  a  long  experience  is  necessary  to  attain 
proficiency  in  the  use  of  the  speculum.  It  is  another  mistake  to  pre- 
sume that  a  trained  assistant  is  necessary  to  its  advantageous  employ- 
ment. The  physician  himself  must  be  the  expert;  he  can  then  easily 
instruct  any  intelligent  person  to  hold  the  speculum  properly.  These 
examinations,  for  obvious  reasons,  should  be  conducted  in  the  presence 
of  a  third  person.  A  gynecologist  of  large  practice  has  an  office  assist- 
ant who  performs  this  service.  A  physician  whose  gynecological  prac- 
tice is  limited  may  either  avail  himself  of  some  member  of  his  house- 
hold in  office  examinations  or  employ  the  Sims-Emmet  self-retaining 
speculum,  which  has  already  been  referred  to  (page  32,  q.  v.).  In 
making  examinations  at  the  home  of  the  patient  the  aid  of  some  mem- 
ber of  her  family  may  be  invoked;  and  this  brings  us  to  make  mention 
of  home  examinations. 

In  order  to  make  these  examinations  satisfactorily  and  to  obtain 
adequate  information  from  them,  the  same  conditions  must  prevail  as 
in  the  consulting  room.  The 
patient  must  be  placed  upon  a 
table,  the  douche  must  be  ad- 
ministered, and  the  bimanual  or 
instrumental  examination  is  to 
be  proceeded  with,  with  the  same 
attention  to  detail.  Whenever 
the  attempt  is  made  to  use  the 
bed  or  couch  dissatisfaction  will 
result.  It  is,  comparatively  speak- 
ing, little  trouble  to  make  the 
home  examination  in  the  proper 
manner.  The  humblest  home  is 
furnished  with  a  four -legged 
table;  this  can  be  covered  with 
blanket,  sheet,  and  protective; 
the  fountain  syringe  can  be  hung 
on  a  nail  near  by,  and  if  an  in- 
strumental examination  is  need- 
ful a  Sims-Emmet  self -retaining 
speculum  can  be  employed.  Or, 
failing  in  the  possession  of  this, 
the  ordinary  Sims  instrument  can 
be  used,  and  an  assistant  to  hold  it  may  be  pressed  into  service  from 
the  household  or  i)ci"'liI)oiirliood. 


Fig.  9. — "  A  good  bivalve  like  Gau's." 
—  Potter  (page  44). 


44 


A  TEXT-BOOK  OF  GYNECOLOGY 


Before  leaving  the  subject 
of  the  speculum  it  is  proper  to 
state  that  the  essential  re- 
quirements for  the  success- 
ful use  of  the  Sims  instru- 
ment are,  first,  the  correct 
position  of  the  patient;  and, 
secondly,  the  proper  hold- 
ing of  the  instrument.  The 
semiprone  posture  can  not 
be  described  in  words  with 
sufficient  clearness  for  a  nov- 
ice to  understand  it;  more- 
over, it  is  difficult  to  illus- 
trate it  clearly,  hence  it  is 
advised  that  a  physician  un- 
familiar with  it  should  place 
himself  under  the  instructions 
of  a  person  who  understands 
it  thoroughly. 

Besides  the  Sims  specu- 
lum, it  is  well  to  have  at 
hand  a  good  bivalve,  like 
Miller's  or  Gau's  (Fig.  9), 
which  gives  a  good  view  of 
the  cervix  (Fig.  10),  as  well 
as  a  trivalve,  the  latter  according  to  Nott's  model  (Fig.  11).  It  occasion- 
ally becomes  necessary  to  examine  the  os  or  cervix  uteri  in  the  dorsal 
position,  and  these  specula  are  well  adapted  to  that  purpose.  (See 
Armamentarium . ) 

In  the  use  of  the  specu- 
lum it  is  sometimes  desira- 
ble to  use  reflected  light 
or  the  intense  rays  of  an 
electric  illuminator.  In 
cases  of  erosion  of  various 
character,  material  assist- 
ance in  diagnosis  may  be 
derived  from  the  use  of 
a  magnifying  glass,  like 
that  devised  for  the  pur- 
pose by  Dr.  Alexander 
Duke,  of  Cheltenham 
(Medical  Press  and  Circu- 
lar, May  15,  1900).  The 
lens,  called  a  hysteroscope,  is  so  arranged  on  a  hinge  that  it  can  be 
placed  at  an  angle  by  the  observer.    By  this  means  the  light  can  be  di- 


FiG.  10.—" . 


Which  gives  a  good  view  of  the 
cervix." — Potter. 


Fig.  11. — "A  trivalve  .  .  .  according  to 
Nott's  model." — Potter. 


DIAGNOSIS 


45 


rected  with  accuracy  upon  the  parts  under  examination,  and  when  used 
with  artificial  light  it  acts  both  as  a  condenser  and  a  magnifier  (Fig.  13). 
The  Sound  as  a  Means  of  Examination. — Formerly  the  sound  was 
considered  an  essential  part  of  the  gynecological  armamentarium,  be- 
cause almost  the  first  thing  done  after  the  in- 
troduction of  the  speculum  was  to  pass  the  sound 
into  the  uterus.  Nowadays,  however,  with  improved 
methods  of  diagnosis,  and  especially  through  a  more 
thorough  understanding  of  the  bimanual,  the  sound 
rarely  is  needed.  Its  chief  purpose  is  to  confirm  the  diagno- 
sis in  doubtful  cases,  such  as  intrauterine 
growths  and  other  intrapelvic  abnormalities 
that  are  misleading  in  their  character.  The 
dangers  of  the  sound  consist  in  its  liability  to 
carry  infection  within  the  genital  tract,  and 
to  puncture  the  uterine  wall;  the  latter  is, 
comparatively  speaking,  an  inconsiderable 
danger,  whereas  the  former  is  a  very  grave 
one.  The  sound  devised  by  J.  F.  W.  Eoss 
(Fig.  13)  is  best  designed  to  obviate  all  dan- 
gers. The  sound  is  no  longer  used  by  the 
experienced  gynecologist  to  reposit  a  dis- 
placed womb,  and  whenever  it  becomes 
necessary  to  use  it  as  an  aid  to  diagnosis, 
first,  it  should  be  made  thoroughly  aseptic, 
and  then  it  should  be  dipped  in  pure  car- 
bolic acid  rendered  liquid  by  the  addition  of 
five  per  cent  of  glycerine,  before  it  is  passed 
into  the  uterus.  With  this  precaution,  and 
with  gentleness  in  manipulation,  the  sound 
I  may  not  do  harm,  and  possibly  it  may  serve 

I  to  clear  up  a  doubtful  diagnosis.     The  probe 

I  is  only  a  modified  sound,  lighter  in   con- 

»— I  struction,  and  much  more  fiexible,  and  prac- 

tically is  used  for  the  same  purpose.  Appli- 
cators, either  of  whalebone  or  aluminum,  are 
useful  in  carrying  certain  medicinal  applica- 
tions within  the  uterine  canal.  If,  however, 
the  uterus  is  sensitive  from  inflammation,  the  use  of  the 
sound,  probe,  or  applicator,  is  contraindicated,  although 
in  some  instances  where  information  is  urgently  needed 
a  very  light  probe  might  possibly  be  introduced  without 
harm.  The  rule  should  be  never  to  pass  the  sound  or 
probo  unless  it  can  be  used  without  causing  pain.  -p      ,„ 

The  Dilator  as  a  Means  of  Examination. — Dilatation  a'pi^ggQu^ji^g. 
of  the  uterus  is  accomplished  by  graduated  bougies,  by  vised  by  J.  F. 
metal  dilators  having  divergent  blades,  by  tents,   or  by    po'tteb. 


Fig.  12. 
"  The  lens  called 
a  hysteroscope." 
— Potter. 


46 


A   TEXT-BOOK  OF   GYNECOLOGY 


rubber  bags  to  be  filled  with  air  or  water.  The  usual  method  is 
through  the  medium  of  the  hard-rubber  graduated  bougie  or  the 
mechanical  steel  dilator  of  Goodell  (Fig.  14).  The  purpose  of  dila- 
tation is  to  make  the  endometrium  accessible  to  certain  therapeutic 
measures,  either  medicinal  or  instrumental.  In  a  narrow,  or  pin-hole, 
OS  it  becomes  necessary  to  dilate  the  channel  before  using 
the  curette  or  making  applications  to  the  endometrium. 
Where  but  little  dilatation  is  required,  occasionally  the 
glove  stretcher  or  metallic  dilator  can  be  used  without  an 
angesthetic;  but  usually  when  it  becomes  necessary  to  em- 
ploy the  more  complicated  instrument  of  Goodell,  anaes- 
thesia to  the  surgical  degree  should  precede  its  use. 
When  the  os  is  patulous,  curettage  for  diagnostic  purposes 
may  be  made  sometimes  without  resorting  to  anesthesia. 
Diagnostitial  dilatation  often  becomes  necessary  for  the 
purpose  of  admitting  the  finger  into  the  uterine  cavity. 
It  is  an  operation,  however,  that  should  never  be  made 
when  there  is  a  sensitive  uterus  to  contend  with,  or  when 
the  pelvic  tissues  have  been  invaded  with  inflammatory 
conditions;  in  other  words,  it  is  necessary  to  surround 
this  operation  with  all  the  precautions  that  pertain  to 
formidable  procedures.  It  is  not  to  be  done  in  the  con- 
sulting room  and  the  patient  allowed  to  make  her  way 
homeward  afterward,  but  it  should  be  done  either  in  hos- 
pital or  at  home,  in  order  that  the  patient  may  be  kept 
entirely  quiet  for  the  next  few  days  thereafter.  This 
operation  is  to  be  preceded  with  the  seizure  of  the  an- 
terior lip  of  the  cervix  by  the  volsella,  or  strong  tenac- 
ulum. The  cervix  is  thus  stretched  and  the  dilator 
gradually  and  slowly  passed  into  the  cervical  canal,  the 
bougie  with  a  rotary  motion,  the  glove  stretcher  with  a 
spreading  of  the  blades  in  a  gentle  manner,  just  within 
the  OS,  advancing  a  little  farther  and  stretching  again, 
and  so  on  until  the  work  is  completed. 
The  Curette  as  a  Means  of  Exam- 
ination.— This  instrument  is  used  to  ob- 
tain scrapings  from  the  endometrium 
with  a  view  to  determine  the  nature  of 

any  disease  that  may  not  otherwise  be  ex-  dilator  of  Goodell."— Potter. 
plained.  These  scrapings  may  be  sub- 
mitted to  examination  by  the  microscope.  If  malignancy  is  ascer- 
tained, the  further  method  of  procedure  is  readily  pointed  out.  If 
there  are  remains  of  an  abortion,  or  an  endometritis  that  has  fol- 
lowed abortion,  then  the  interior  of  the  uterus  should  be  thoroughly 
cleaned,  mopped  with  pure  carbolic  acid  or  carbolic  acid  and  iodine, 
and  the  organ  should  be  packed  with  antiseptic  gauze.  The  curette 
is  often  used  unnecessarily,   and  great  caution   should  be   observed 


14.- 


i'chanieal  steel 


DIAGNOSIS  47 

in  its  employment.  The  puerperal  womb  is  easily  perforated,  an 
accident  that  has  often  happened  in  unskilful  hands. 

The  Cystoscope  as  a  Means  of  Diagnosis. — (See  Examination  of  the 
Bladder.) 

The  Aspirator  as  a  Means  of  Examination. — This  instrument  is 
sometimes  appealed  to  when  cysts  or  pus  pockets  develop  along  the 
broad  ligament.  In  doubtful  cases  these  sacs  may  be  explored  through 
the  roof  of  the  vagina,  but  it  is  generally  sufficient  to  diagnosticate 
them  by  the  usual  means,  and  to  evacuate  them  by  surgery  through  the 
abdomen  or  vagina. 

The  stethoscope  is  occasionally  employed  to  ascertain  the  nature  of 
abdominal  diseases,  especially  when  pregnancy  is  suspected.  The  uter- 
ine dressing  forceps  and  the  depressor  are  an  essential  accompaniment 
to  the  armamentarium  and  need  no  particular  description.  The  forceps 
carries  cotton  in  wiping  the  tract,  and  the  depressor  holds  the  bladder 
away  from  the  field  during  inspection.  The  tenaculum  and  volsella 
are  used  to  seize  the  lips  of  the  uterus  in  order  to  draw  down  the  organ 
or  to  steady  it  while  the  parts  are  being  inspected  and  applications 
are  being  made.  These  instruments  should  be  dipped  in  pure  carbolic 
acid  before  using. 

Examination  of  the  Urinary  Tract. — (See  Examination  of  the  Se- 
cretions and  Diseases  of  the  Urinary  Tract.)  With  this,  should  be  asso- 
ciated a  systematic  investigation  of  the  various  parts  of  the  body. 
It  is  well  enough  for  convenience'  sake  to  begin  with  the  upper 
air-passages;  nose,  throat,  and  fauces,  should  be  investigated,  'pa.v- 
ticularly  in  cases  in  which  there  exist  head  or  nerve  symptoms,  so 
frequently  referred  to  as  genital  reflexes.  A  similar  investigation  under 
similar  circumstances  should  be  made  of  the  eyes  and  ears.  Careful 
auscultation  and  percussion  of  the  heart  and  lungs  should  be  made 
when  there  are  irregularities  of  the  former,  or  when  the  latter  may  be 
subjected  to  suspicion  by  pelvic  or  other  symptoms  suggestive  of 
tuberculosis.  It  is  not  presumed  that  every  practitioner  is  capable 
of  making  a  thorough  examination  of  each  of  these  several  organs; 
but  any  one  who  assumes  to  practise  gynecology  should  be  so  thor- 
oughly grounded  in  a  general  knowledge  of  medical  science  that  he 
can,  with  reasonable  accuracy,  determine  departures  from  health  in 
all  bodily  structures  or  functions.  If  it  is  necessary  to  carry  an 
examination  of  any  of  these  organs  to  the  point  of  technical  perfection, 
they  can  be,  and  should  be,  relegated  to  special  practitioners  for  that 
purpose. 

Intrapelvic  disease  is  a  fruitful  cause  of  perversions  of  practically 
all  of  the  secretions.  These  functional  disturbances,  in  turn,  become 
factors  in  the  case  and  need  to  be  dealt  with  as  such. 

The  Urines. — In  consequence  of  the  great  advance  which  has  been 
made  in  the  study  of  pathologic  conditions  of  the  genito-urinary  tract, 
and  in  view  of  the  fact  that  the  urine  secreted  by  either  kidney  differs 
from  that  secreted  by  the  other,  it  is  now  important  to  speak,  not  of 


48  A   TEXT-BOOK  OF   GYNECOLOGY 

the  urine,  but  of  the  urines,  when  reference  is  made  to  the  secretions 
which  accumulate  in  the  bladder.  The  technique  involved  in  securing 
the  urine  from  either  kidney  is  considered  in  the  chapter  devoted  to 
that  subject.  The  investigation  of  the  blended  urines,  however,  is  still 
a  matter  of  clinical  importance.  Care  should  be  taken  to  determine 
their  quantity,  colour,  and  specific  gravity,  the  presence  or  absence  of 
albumin,  glucose,  mucus,  tube  casts,  pus,  or  other  morbid  products. 
In  view  of  the  importance  of  xanthine  and  the  paraxanthines  in  the 
causation  of  various  nervous  jjhenomena,  an  examination  of  the  urine 
will  frequently  need  to  embrace  a  qualitative  and  quantitative  deter- 
mination of  these  substances.  Urea  and  uric  acid  are  of  clinical  im- 
portance and  need  to  be  studied.  In  many  cases  it  will  be  important, 
not  only  to  study  the  urine  from  each  kidney,  but  also  to  study  each 
urine  and  the  blended  urines  repeatedly.  To  insure  completeness  of 
examination  it  is  important  to  follow  the  usual  blanks  available  for 
the  purpose. 

Faeces. — In  many  gynecologic  cases,  particularly  in  those  associated 
with  marked  disturbances  of  nutrition,  it  is  of  great  importance  to 
investigate  carefully  the  faeces.  Their  naked-eye  characteristics  should 
be  noted,  and  microscopic  studies  should  be  made  of  various  kinds  of 
their  constituents.  Blood,  fats,  parasites,  fungi,  foreign  bodies,  mucin, 
ferments,  hydatids,  etc,  are  only  mentioned  to  suggest  the  range  of  in- 
quiry which  should  be  made  in  many  of  these  cases.  The  reader  is 
referred  to  Jaksch's  Clinical  Diagnosis. 

The  Menstrual  Discharge. — It  is  often  important  to  determine  with 
accuracy  the  quality  and  quantity  of  the  menstrual  discharge.  To 
determine  its  character  the  napkins  should  be  preserved  and  inspected. 
It  should  be  remembered,  however,  that  the  absorption  of  the  blood  by 
the  napkin  modifies  to  an  important  degree  the  colour  of  the  former.  If 
more  critical  examination  needs  to  be  made,  some  of  the  discharge  can 
be  mounted  upon  a  slide  and  put  under  the  microscope.  If  there  is 
occasion  to  ascertain  the  quantity  passed,  the  napkins  should  be  care- 
fully weighed  before  and  after  being  used.  In  some  cases  it  is  impor- 
tant to  determine  whether  the  discharge  is  a  true  menstrual  flow  or  a 
lochial  discharge.  For  this  purpose  the  microscopic  examination  is 
essential.  It  may  be  mentioned  in  this  connection  that  in  the  men- 
strual flow  immediately  after  its  onset,  there  occur  abundant  red  blood- 
corpuscles  and  prismatic  epithelial  cells  laden  with  fat.  These  are 
derived  from  the  interior  of  the  uterus.  As  soon  as  the  physiologic 
climax  of  the  flow  has  been  reached,  the  red  blood-cells  diminish  and 
the  leucocytes  progressively  increase  until  the  flow  disappears.  The 
fluid  which  passes  following  a  parturition,  is,  in  the  absence  of  hemor- 
rhage, thinner  in  consistence,  with  less  tendency  to  coagulate.  While 
it  abounds  in  red  and  white  corpuscles  from  the  start,  it  shows,  also, 
abundant  epithelium  from  both  the  uterus  and  vagina.  Unlike  men- 
strual fluid,  the  lochia,  even  in  the  absence  of  septicsemia,  abound  in 
microbes. 


DIAGNOSIS  '  49 

The  Blood. — Every  pi-actitioner  should  provide  himself  with  the 
necessary  instruments  for  the  examination  of  the  blood.  These  should 
include  an  apparatus  for  counting  the  blood-corpuscles,  chromo-cytom- 
eter,  and  a  hemometer.  AVith  these  instruments  and  a  good  n^icro- 
scope,  with  which  all  modern  practitioners  are  presumed  to  be  pro- 
vided, it  will  be  possible  to  determine  the  blood  state  of  patients. 
This  is  an  exceedingly  important  diagnostitial  measure  in  gynecological 
practice.  Thus  a  marked  leucocytosis,  taken  in  connection  with  other 
symptoms,  is  confirmatory  of  a  suppuration  which  may  be  situated  so 
remotely  in  the  pelvis  as  to  defy  detection.  Oligochromsemia,  in  vary- 
ing degrees,  may  be  accepted  as  an  index  of  general  states  of  nutrition; 
the  perturbation  of  which  may  depend,  in  the  first  instance,  upon  ob- 
scure and  otherwise  undetectable  conditions  within  the  pelvis.  Eeed 
has  shown  [American  Journal  of  Obstetrics  and  Gynecology)  that  many 
perverted  conditions  of  the  blood  are  caused  in  the  first  instance  by 
disease  of  the  pelvic  organs,  the  disturbing  influence  of  which  is  exer- 
cised, through  the  intimate  nerve  connections,  upon  the  hematogenetic 
function.  When  these  changes  and  their  causation  are  better  under- 
stood, the  diagnostic  value  of  blood  states,  considered  as  indicative  of 
intrapelvic  disturbances,  will  be  greatly  enhanced. 

The  Nervous  System. — The  intimate  relation  of  the  entire  genital 
apparatus  with  the  nervous  system  (see  ISTervous  Complications  in 
Gynecology)  renders  it  important  that  the  gynecologist  should  make  a 
careful  note  of  the  actual  state  of  the  nerve  functions.  He  should  learn 
to  appreciate  nerve  disturbances  as  much  from  the  neurologic  as  from 
the  gynecologic  standpoint.  Motor  and  sensory  disturbances  should  be 
determined  by 'instruments  of  precision,  while  the  special  senses  should 
be  investigated  with  acciiracy.  Psychic  states  should  be  studied  with 
care.  Careful  attention  to  these  precautions  will  speedily  result  in 
reducing  the  now  chaotic  subject  of  "  genital  reflexes  "  to  a  somewhat 
scientific  basis. 


CHAPTER    VII 
SEPSIS 

Sepsis  defined — The  bacteria  of  sepsis — Local  sepsis:   Symptoms,  pathology,  and 
treatment — General  sepsis:  Symptoms,  pathology,  and  treatment. 

Sepsis — derived  from  the  Greek  word  arjifns  (from  o-rjirecrOai,  to  rot) ; 
French,  sepsie;  German,  Fdulnis — is  defined  by  Foster  as  putrefaction, 
rotting;  in  medicine,  the  morbid  condition  resulting  from  the  absorp- 
tion of  putrid  or  putrescent  material  or  of  germs  capable  of  causing 
putrefaction.  As  used  in  this  connection  it  implies  a  condition  of 
either  {a)  local,  or  (6)  general,  infection  by  pathogenic  micro-organisms. 
The  relation  of  bacteria  to  fermentation  and  putrefaction  Avas  first 
demonstrated  by  Pasteur,  from  which  phenomena  he  deduced  the  the- 
ory that  suppuration  in  wounds  was  probably  due  to  external  agencies, 
and,  by  subsequent  experiments,  demonstrated  the  correctness  of  his 
analogy.  The  theory  thus  established  found  its  first  practical  appli- 
cation at  the  hands  of  Lister,  who,  by  a  succession  of  careful  and 
painstaking  experiments  and  clinical  observation,  laid  the  foundation 
for  the  technique  of  antisepsis.  The  entire  practice  is  based  upon  the 
now  demonstrated  and  accepted  fact  that  micro-organisms  are  the 
essential  factors  in  the  causation  of  both  local  and  general  sepsis. 
These  micro-organisms  embrace  both  micrococci  and  bacilli,  a  compre- 
hension of  the  identity  and  pathogenesis  of  each  of  which  is  essential 
to  an  understanding  of  sepsis,  its  prevention,  and  treatment. 

The  Bactekia  of  Sepsis 

Micrococci. — Of  the  micrococci  both  the  staphylococci  and  the 
streptococci  play  important  parts,  often  coincidently,  in  producing 
sepsis. 

(A)  Staphylococci,  although  occurring  in  several  varieties,  have  a 
more  or  less  common  morphology  in  the  particulars  that  they  are  (a) 
small,  spherical  cells;  (b)  that  they  vary  from  0.7  /*  to  0.9  /*  in  diam- 
eter; that  they  occur  singly,  in  pairs  (diplococci),  frequently  in  fours 
(tetrads),  or  in  masses  (zoogloea).  The  varieties  about  to  be  considered 
differ  from  each  other  chiefly  in  colour,  the  character  of  the  pigment 
they  throw  off,  their  behaviour  in  different  media,  their  degrees 
of  virulence,  and  finally  in  the  particular  of  their  natural  habitat. 
While  there  are  other  varieties  of  staphylococci,  but  four  will  be  con- 
sidered in  this  connection — viz.:  (1)  The  Staphylococcus  pyogenes  aureus 
is  the  most  common  pathogenic  micrococcus  (Fig.  15).  Having  the 
50 


SEPSIS  51 

morphologic  feature  already  mentioned,  it  is  only  important  to  add  that 
it  multiplies  rapidly  at  normal  temperatures  in  nutrient  media.  While 
growing  in  gelatine,  which  these  cocci  liquefy,  they  accumulate  near 
the  surface,  producing,  when  brought  in  contact  with  the  air,  a  charac- 
teristic golden-yellow  pigment  which  is  precipitated  to  the  bottom  of 
the  tube  and  from  which  they  take  their  name.  Sternberg  gives  the 
thermal  death  point  in  moist  media  at  from  56°  to  58°  C.  (132.8°  to 
136.4°  F.),  but  when  dried  at  from  90°  to  100°  C.  (194°  to  213°  F.) 
these  germs  grow  in  either  the  presence  or  absence  of  oxygen,  and 
are  capable  of  reproducing  themselves  when  transplanted  from  nutrient 
media  at  the  end  of  a  year,  and  they  have  been  found  alive  at  the 
end  of  ten  days  after  having  been  dried 
on  a  cover  glass.  Their  natural  habitat 
on  the  body  is  the  cutaneous  and  mu- 
cous surfaces,  although  they  have  been 
found  in  the  salivary  secretions,  in  the 
dirt  under  the  finger  nails,  and  in  the 
mucus  from  both  the  pharynx  and  nose; 
they  have  also  been  found  in  the  soil, 
the  air  and  water,  upon  the  surface  of 
fruits,  and  on  the  petals  of  the  rose.  The 
pus-forming  quality  of  this  coccus  is  be-  fig.  i5.-"The  titap^ylococcus 
yond  doubt.     Von  Eiselberg  and  Netter  pyogenes  aureus  is  the  most 

have  shown  that  it  is  transported  by  the  common   pathogenic    micro- 

T  1       T     ,  ,  1  ,  p    ,  1  ,  1      ,  coccus." — Reed  (page  50). 

blood  to  other  parts  of  the  system,   but  '^  ^      ' 

there  is  no  conclusive  evidence  that  it  multiplies  within  that  medium. 
(2)  The  Staphylococcus  pyogenes  alius  is  precisely  like  the  preceding 
in  morphology  except  that  it  is  not  pigmented.  Surface  cultures 
made  from  this  coccus  are  milk  white,  from  which  fact  it  takes  its 
name.  According  to  Eosenbach,  who  discovered  it,  this  albus  occurs 
more  commonly  among  the  lower  animals  than  does  the  aureus.  Patho- 
logically it  is  often  found  alone  in  acute  abscesses,  but  more  frequently 
in  company  with  other  pyogenic  bacteria.  It  is  probably  identical  with 
the  micro-organism  next  to  be  described.  (3)  The  Staphylococcus  epi- 
derm.idis  albus  (Welch)  has  physical  properties  precisely  like  those  of 
the  preceding,  but  differs  from  the  aureus  in  colour,  in  the  fact  that  it 
liquefies  gelatine  more  slowly,  that  it  is  less  virulent  when  introduced 
into  the  tissues,  and  that  it  may  be  present  in  wounds  without  causing 
pus.  This  latter  statement  is  made  by  Welch  in  face  of  the  declaration 
that  it  has  been  demonstrated  to  be  the  frequent  sole  cause  of  suppura- 
tion along  the  drainage  tube  and  in  stitch  abscesses.  Its  natural  habitat 
is  the  skin,  into  the  interstices  of  which  it  is  frequently  buried  so 
deep  as  to  be  beyond  the  reach  of  the  agents  usually  employed  in  hand 
sterilization.  This  was  interestingly  demonstrated  by  Dr.  Thomas  C. 
Craig,  United  States  Navy  {New  York  Medical  Journal,  April  11,  1896), 
who,  in  a  search  for  malarial  organisms  in  a  fever  patient,  sterilized  the 
palmar  surface  of  the  lattei-'s  finger,  which  he  pricked  deeply  with  a 


52  A   TEXT-BOOK   OF   GYNECOLOGY 

needle  previously  sterilized  in  an  alcohol  flame.  Three  drops  of  the 
resulting  blood  were  thrown  away;  the  top  of  the  next  drop  was  touched 
with  the  point  of  a  sterilized  platinum  wire  and  a  stab  culture  in  agar 
made.  Three  cultures  were  thus  made,  two  of  which  proved  negative, 
while  the  third  yielded  the  Staphylococcus  epidermidis  albus  of  Welch. 
AYhile  this  is  an  isolated  observation  it  tends  to  show  that,  even  upon  a 
palmar  surface,  in  the  absence  of  sebaceous  glands  and  hair  follicles, 
this  coccus  may  be  situated  so  deeply  as  to  elude  careful  antiseptic 
precautions.  (4)  The  Staphylococcus  pyogenes  citreus,  while  having 
morphologic  features  in  common  with  other  micrococci,  differs  from 
them  in  the  particulars  that  its  coloured  pigment  is  of  a  lemon  yellow, 
that  its  pigment  is  formed  only  in  presence  of  oxygen,  that  it  is  slowest 
of  all  of  the  micrococci  in  liquefying  gelatine,  and,  finally,  that  al- 
though it  is  found  with  other  bacteria  in  acute  abscesses,  its  own 
jDathogenesis  is  undetermined. 

(B)  Streptococci,  like  the  preceding  organisms,  have  a  common  mor- 
phology depending  upon  the  fact  that,  after  the  cocci  have  multiplied 
by  binary  division  in  a  single  direction,  the  resulting  segments  arrange 
themselves  into  chains  (Fig.  16).  The  chains  thus  formed  may  be  long 
or  short,  single  or  arranged  into  bundles.  While  there  are  numerous 
varieties  of  streptococci,  it  is  necessary  for  this  chapter  to  consider 
only  the  Streptococcus  pyogenes,  in  which  the  cocci  are  spherical — from 
0.1  /A   to  1  /u.   in  diameter — those  in  the  same  chain  or  in  different 

chains  varying  in  diameter.  This  strep- 
tococcus grows  both  in  the  presence  and 
absence  of  oxygen  and  does  not  liquefy 
gelatine.  Considered  pathogenetically,  it 
causes  inflammation  when  injected  into 
the  tissues  of  lower  animals,  in  some  of 
which,  notably  in  mice,  with  lowered  vital- 
ity, it  multiplies  within  the  body  and  causes 
death.  It  is  demonstrated  to  be  the  essen- 
tial causative  factor  in  erysipelas,  from 
which  fact  it  is  sometimes  designated  the 
Fig.  16.— "After  the  cocci  have  Streptococcus  crysipeltttos.  It  is  also  recog- 
multiplied  by  binary  division     nised    as    the    streptococcus    of    puerperal 

in  a  single  direction,  the  result-      ^  ^  ^^^^  ^^^.^j^   explains   the   noW   uni- 

ing   segments    arrange   them-  -111 

selves  into  chains."-EEED.  versally  recogniscd  causal  relation  of  ery- 
sipelas to  the  latter  disease.  Czerniewski 
found  this  coccus  but  once  in  the  lochia  of  57  healthy  lying-in  women, 
while  he  found  it  in  the  lochia  of  35  out  of  38  women  with  puerperal 
fever,  and  in  10  fatal  cases  it  was  present  in  the  lochia  before  and  in 
the  organs  after  death.  The  inference  from  these  observations  has 
been  abundantly  conflrmed,  especially  by  Clivio,  Widal,  Eiselberg, 
Emerich,  and  Bumm.  It  also  plays  an  important  part  in  the  inflam- 
mation of  mucous  membranes. 

The  Micrococcus  gonorrlmce,  familiarly  known  as  the  gonococcus  of 


SEPSIS 


53 


Fig.  17. — "Familiarly  known  as 
the  gouococcus  of  Neisser." — 
Reed. 


Neisser  (Fig.  17),  is  a  micrococcus  occurring  in  pairs  or  in  groups  of 
four,  but  generally  in  the  form  of  diplococci.  Its  elements  are  flattened 
or  "  biscuit-shaped."  "  The  flattened  surfaces,"  says  Sternberg,  "  face 
each  other  and  are  separated,  in  stained  preparations,  by  an  unstained 
interspace.  The  diameter  of  an  associated  pair  of  cells  varies  from  0.8  ft 
to  1.6  /A  in  the  long  diameter — average  about  1.25  fi — and  from  0.6  /a 
to  0.8  ft,  in  the  line  of  the  interspace  between  the  biscuit-shaped 
elements,  which  sometimes  present  a  slight  concavity  of  the  flattened 
surfaces.  Multiplication  occurs  alternately 
in  two  planes,  and  as  a  result  of  this,  groups 
of  four  are  frequently  observed.  But  diplo- 
cocci are  more  numerous  and  are  considered 
as  the  characteristic  mode  of  grouping. 
Single,  spherical,  undivided  cells  are  rarely 
seen."  There  are  other  micro-organisms 
with  a  morphology  identical  with  the  gono- 
coccus,  which,  therefore,  must  depend  for  its 
distinction  upon  other  features.  Among 
other  facts  to  be  taken  into  consideration  in 
this  connection  are  its  response  to  staining 
agents;  the  fact  that  it  is  aerobic;  that  it  is 
a  strict  parasite;  that  in  culture  media  it 

is  self-limiting  in  its  vitality;  that  it  will  not  develop  below  25°  C. 
(77°  F.)  or  above  38°  C.  (100.4°  F.);  that,  exposed  to  60°  C.  (140°  F.) 
for  ten  minutes,  it  dies;  and,  finally,  it  is  distinguished  by  the  clinical 
phenomena  attending  its  occurrence.  Studied  pathogenetically,  it  has 
been  demonstrated  to  cause  the  form  of  inflammation  known  as  gonor- 
rhoea, upon  the  mucous  membrane  of  the  urethra,  the  cervix  uteri,  the 
corpus  uteri,  and  the  vagina  of  children;  while  the  vaginal  mucous 
membrane  of  adults  appears  to  be  immune.  The  conjunctiva  is  also 
capable  of  inoculation — a  fact  which  accounts  for  the  frequent  occur- 
rence of  ophthalmia  neonatorum.  Bockhart  has  found  that  the  gono- 
cocci  penetrate  into  the  deeper  layers  of  the  urethral  mucous  mem- 
brane, even  into  the  corpus  cavernosum,  although  Bumm  is  of  the 
opinion  that,  as  a  rule,  the  epithelial  layer  of  the  mucous  membrane  is 
alone  involved.  In  its  later  stages  gonorrhoea  often  becomes  a  mixed 
infection,  owing  to  the  presence  of  the  Staphylococcus  pyogenes  aureus, 
upon  which,  rather  than  upon  the  gonococcus,  all  metastatic  manifesta- 
tions depend. 

Bacilli. — The  pathogenic  bacilli,  like  the  micrococci,  have  a  com- 
mon morphology,  in  the  particulars  that  they  are  spheroidal,  rod- 
shaped,  or  spiral  in  form  (Fig.  18).  The  ends  of  the  rods  may  differ, 
some  being  square,  others  oval,  etc.,  the  difference  existing  between 
the  ends  of  different  rods  rather  than  of  the  same  rods.  Of  the 
several  hundred  known  bacilli  it  is  necessary  in  this  connection  to  con- 
siflcr  })nt  three — viz.:  (a)  Bacillus  coli  communis,  (b)  Bacillus  aerogenes 
capsvIdJ/us,  iinfl  (c)  the  liacillus  tuberculosis. 


54 


A  TEXT-BOOK  OF   GYNECOLOGY 


(a)  The  Bacillus  coli  communis,  morphologically,  consists  of  short 
rods  with  rounded  ends,  generally  occurring  in  pairs  (Fig.  19),  about  2  /* 
long  and  from  0.4  /a  to  0.6  /a  broad.  In  some  instances  the  diameter  and 
the  length  are  equal,  under  which  circumstances  they  may  be  mistaken 
for  micrococci.  They  propagate  both  with  and  without  oxygen,  and 
are  both  parasitic  and  saprophytic.  They  are  capable  of  slight  amceboid 
activity.     They  propagate  actively  in  acid  media  of  abnormal  tempera- 


FiG.  18. — "Bacilli  are  spheroidal,  rod-shaped, 
or  spiral  in  form." — Eeed  (page  53). 


Fig.  19.- 


The  Bacillus  coll  communis. 
— Keed. 


ture.  There  are  several  varieties  of  this  bacillus,  all  of  them  possessing 
a  common  mor^jhology  though  differing  slightly  in  habitat,  behaviour 
in  similar  media,  and  in  degrees  of  virulence,  but  it  is  not  necessary  in 
this  connection  to  speak  of  them  in  detail.  In  the  normal  body  the 
habitat  of  the  Bacillus  coli  communis  is  in  the  colon  and  adjacent  por- 
tions of  the  alimentary  canal.  Its  migration  from  this  locus,  through 
an  infection  atrium,  into  either  the  walls  of  the  intestines  or  the  peri- 
toneal cavity  is  fraught  with  serious  mischief.     (See  Bacteriology  of 


Fig.  '20. — "  The  Bacillus  aerogenes  capsu- 
latus  (Welch-Nuttall.)" — Eeed. 


Fig.  21. — ''The  Bacillus  tuberculosis 
(Koch.)" — Eeed  (page  55). 


Appendicitis.)     It  has  been  found  in  common  with  other  micro-organ- 
isms in  puerperal  fever. 

(&)  The  Bacillus  aerogenes  capsulatus  (Welch-Nuttall,  Fig.  30)  oc- 
curs, ordinarily,  as  a  straight  but  sometimes  slightly  curved  bacillus, 
with  ends  that  may  be  square  or  slightly  rounded,  and  from  3  to  6  //.  in 


SEPSIS  55 

length.  It  has  a  transparent  capsule;  is  without  the  power  of  spon- 
taneous movement;  is  sporeless;  thrives  without  oxygen  at  noraial  tem- 
perature; and  generates  gas  in  large  quantities  in  all  culture  mediums. 
Animals  inoculated  with  this  bacillus  sjieedily  die^,  the  bacillus  propa- 
gating rapidly  and  developing  gas  in  the  dead  tissues.  It  is  the  bacillus 
most  probably  responsible  for  the  gas  which  occasionally  occurs  in 
tissues  in  connection  with  suppuration. 

(c)  The  Bacillus  tuberculosis  (Koch,  Fig.  21)  consists  of  rods  from 
1.5  /A  to  3.5  //.  long  and  from  0.2  fi  to  0.25  /u.  broad.  They  are  gener- 
ally slightly  curved,  but  sometimes  angulated,  and  in  stained  specimens 
exhibit  unstained  intervals.  They  are  usually  single,  but  are  occasion- 
ally double.  They  are  peculiar  in  that  they  do  not  readily  take  up  ani- 
line colours,  and  that  when  once  stained  they  do  not  decolourize  with 
facility,  even  by  strong  acids.  They  are  parasites,  but  under  ordinary 
circumstances  they  are  not  saprophytic.  They  grow  only  at  a  tempera- 
ture of  about  37°  C.  (98.6°  F.),  and  that  they  develop  spores  in  the  pro- 
cess of  growth  is  not  established.  Koch  affirms  that  they  are  killed  by 
exposure  to  the  direct  rays  of  light,  although  Sawizky  states  that  tuber- 
culous sputum,  u.nder  the  conditions  of  ordinary  habitation,  may  retain 
infectious  power  for  as  long  as  ten  weeks.  A  fact  of  practical  impor- 
tance is  that  they  develop  a  toxine  which  produces  febrile  reaction. 
Pathogenetically,  it  is  sufficient  for  the  present  purpose  to  say  that, 
introduced  into  the  system,  this  bacillus  causes  tuberculosis  both  in  the 
lower  animals  and  man. 

Varieties  of  Sepsis. — For  the  purposes  of  this  work  sepsis  is  divided 
into  local  and  general. 

Local  sepsis  implies  the  infection  of  a  circumscribed  area  of  tis.sue 
with  pathogenic  bacteria.  Such  infection  results  generally,  but  not 
always,  in  suppuration,  which  may  be  either  superficial,  as  in  ulcera- 
tion, or  interstitial,  as  in  the  formation  of  an  abscess.  Suppuration 
consists  in  the  conversion  of  normal  tissue  elements  into  a  fluid  called 
pus.  Pus  is  of  variable  consistence,  of  high  specific  gravity,  of  alkaline 
reaction,  and  of  a  colour  varying  from  grayish  to  greenish  yellow. 
Any  variation  from  yellow  depends  upon  the  presence  in  the  pus  of 
added  elements.  Microscopically,  pus  is  found  to  contain  leucocytes, 
some  of  which  are  normal  in  size  and  contour,  others  are  dead  and 
shrunken,  while  still  others  are  very  large  and  polynuclear,  and  are 
known  as  giant  or  pus  corpuscles.  There  are  some  red  blood-corpus- 
cles, frequent  fat-laden  cells,  and  some  epithelial  elements.  Passet 
cultivated  from  pus  eight  difl^erent  kinds  of  fungi,  chief  among  which 
were  the  staphylococci,  streptococci,  and  bacilli  of  various  sorts;  among 
the  last,  in  different  cases,  were  observed  the  bacillus  of  tuberculosis, 
the  bacilli  of  glanders,  of  leprosy,  and  actinomyces.  Filiaria  and 
infusoria  are  also  occasionally  found.  The  crystalline  elements  of  pvis 
are  cholesterin,  hematoidin,  tbe  ciystals  of  fatty  acids,  and  the  triple 
phosphates. 

The  treatment  of  sepsis  divides  itself  naturally  into  preventive  and 


56  A   TEXT-BOOK  OF   GYNECOLOGY 

curative.  Under  the  first  head  are  embraced  all  those  measures 
which  are  calculated  to  destroy  the  pathogenic  bacteria  existing 
upon  the  integument  or  upon  dressings,  instruments,  ligatures,  or 
sutures,  and  which  may  thence  and  thereby  be  brought  in  contact 
with  such  tissues  as  may  be  exposed  in  the  course  of  a  surgical  oper- 
ation. They  are  designed  to  produce  a  condition  known  as  asepsis. 
This  word  deserves  a  little  consideration;  its  definition,  as  given  by 
Foster,  is  as  follows: 

Asepsis — from  a  privative  and  cnyi/^ts,  putrefaction;  French,  asepsie; 
German,  Asepsie — means  freedom  from  j)utrid  or  putrescent  material 
and  from  septic  germs. 

It  has  come  to  be  used,  in  surgical  nomenclature,  to  imply  an  ex- 
alted state  of  ordinary  cleanliness,  to  secure  which  it  is  not  necessary  to 
employ  the  usual  germicidal  measures  and  agencies.  In  many  quarters 
it  is  accepted  as  true  that  asepsis  is  a  very  natural  condition.  This  view 
is  misleading  and  dangerous.  The  very  contrary,  indeed,  may  be  as- 
serted— namely,  that  the  condition  of  absolute  asepsis,  particularly  as 
relates  to  the  human  integument,  not  only  does  not  exist  naturally, 
but  is  almost  impossible  of  attainment.  This  being  true,  the  word 
"  asepsis "  should  be  used  only  to  imply  such  a  state  of  freedom 
from  septic  elements  as  can  be  attained  by  the  use  of  antiseptic 
measures  and  agencies.  As  a  matter  of  fact,  all  the  measures  and 
precautions  usually  designated  under  that  head  are  directed  against 
septic  micro-organisms  and  are  consequently  measures  of  anti- 
sepsis. This  word — from  avri,  opposed  to,  and  a-rjil/i<s,  putrefaction 
(French,  antisepsie;  German,  Fdulnishemmung) — ^means  any  procedure 
or  combination  of  procedures  for  preventing,  limiting,  or  stopping, 
putrefaction  or  for  destroying  putrefactive  germs. 

The  attempted  limitation  of  the  meaning  of  "  antisepsis  "  to  the 
treatment  of  conditions  of  obvious  infection  is  not  warranted  by  its 
etymology  or  by  its  recognised  scientific  application.  Those  antiseptic 
measures  which  are  adopted  as  preliminary  safeguards  to  an  operation 
may  properly  be  grouped  under  the  title  of  the  preventive  treatment 
of  sepsis.    (See  Antisepsis.) 

Symptoms  of  Local  Sepsis. — A\lien  local  infection  occurs,  it  causes 
a  circumscribed  inflammation,  characterized  by  the  cardinal  signs  of 
heat,  pain,  redness,  and  swelling.  In  the  course  of  a  few  days,  if  the 
infection  has  not  been  mastered  by  the  action  of  the  leucocytes,  pus 
forms;  the  micro-organisms  upon  which  it  depends  for  its  elaboration, 
having  penetrated  into  the  normal  tissues,  continue  to  propagate,  re- 
sulting in  the  progressive  formation  of  pus.  This  is  observable  in  areas 
of  infection  upon  the  surface,  as  well  as  in  the  gradually  increasing 
volume  of  an  abscess. 

Treatment  of  Local  Sepsis. — The  fact  that  pyogenic  bacteria  are 
inhibited  at  low  temperatures  is  of  practical  importance  in  the  treat- 
ment of  the  earlier  stages  of  local  infection.  Cold,  applied  persistently 
over  the  seat  of  infection  not  too  deep  to  be  influenced  by  it,  may 


SEPSIS  57 

arrest  the  propagation  of  the  bacteria  until  the  leucocytes  have  had 
time  to  subdue  the  advance  guard  of  invasion.  Cold  is,  therefore,  a 
remedy  of  great  value  in  the  early  treatment  of  these  cases,  when  for 
any  reason  it  is  not  deemed  best  to  open  the  wound  and  treat  it  by 
direct  antisepsis.  This  is  the  course  of  election  in  the  majority  of 
cases.  The  focus  of  infection  should  be  freely  incised  and  washed 
out,  first,  with  sterilized  alkaline  water,  next  with  hydrogen  peroxide, 
and  subsequently  with  the  bichloride  solution.  The  wound  should 
then  be  packed  with  bichloride  gauze  and  changed  daily.  If  the  wound 
still  manifests  a  tendency  to  suppurate,  the  fact  indicates  that  the  bac- 
teria have  penetrated  too  deeply  to  be  influenced  by  the  antiseptic 
agents.  It  is  better,  under  such  circumstances,  to  freely  curette  the 
wound  down  to  the  normal  and  unaffected  tissues,  then  to  wash  it  out 
with  the  peroxide,  and  treat  it  as  before.  Active  escharotics,  such  as 
the  nitrate  of  silver,  may  be  used  to  cauterize  the  wound,  and  thus  to 
remove  the  infected  tissues. 

General  sepsis,  as  used  in  this  chapter,  means  the  intoxication  of 
the  system  with  some  poisonous  agency  of  bacterial  origin,  and  includes 
the  clinical  conditions  designated  by  toxcemia,  septiccemia,  saprcemia, 
pycemia,  etc.  The  state  of  general  sepsis  presupposes  a  point  of  local 
infection,  although  the  local  infection  may  not  result  in  suppuration. 
There  are  many  cases  of  general  sepsis  in  which  the  constitutional 
symptoms  develojD  and  run  to  a  fatal  issue  before  the  local  infection, 
upon  which  they  depend,  has  had  time  to  develop  suppuration.  That 
constitutional  sepsis  depends  primarily  upon  local  bacterial  invasion 
is  established  by  (a)  the  frequency  with  which  it  follows  known  local 
infection,  (i)  the  extreme  rarity  of  its  occurrence  in  the  absence  of 
some  demonstrable  nidus  of  infection,  and  (c)  the  demonstrated  exist- 
ence in  the  blood  of  bacteria  which  of  necessity  must  have  had  an 
extra  corporeal  origin.  Yon  Eiselberg  has  demonstrated  both  staphylo- 
cocci and  streptococci  in  the  blood  of  septic  patients.  While  the  role 
that  these  bacteria  play  in  the  circulation  can  not  be  doubted,  it  has, 
nevertheless,  been  proved  by  Eosenbach  that  actual  bacterial  invasion 
of  the  circulation  is  not  essential  to  the  causation  of  constitutional 
sepsis;  he  concludes,  on  the  contrary,  that  septic  symptoms  are  due 
rather  to  the  absorption  of  poisonous  ferments  and  ptomaines. 
These,  having  their  origin  in  a  local  infection,  are  given  off 
and  multiply  more  rapidly  than  do  the  micro-organisms  them- 
selves. It  is  this  latter  fact  which  explains  the  celerity  Avith 
wliich  septic  symptoms  develop  after  a  local  infection  hfs  occurred  in 
cases  in  which  bacteria  can  not  be  demonstrated  in  the  blood.  In  cer- 
tain cases,  bowever,  bacteria  are  present  in  large  numbers,  a  few  of  them 
succumbing  to  the  action  of  the  leucocytes,  while  others  are  deposited 
in  the  terminal  capillaries,  where  they  become  foci  of  secondary  sup- 
puration. Reed  has  recorded  a  case  in  which  one  hundred  and  twenty- 
four  secondary,  or  metastatic,  abscesses  occurred,  in  which  the  patient 
finally  recovered. 


58  A  TEXT-BOOK  OF   GYNECOLOGY 

Symptoms  of  General  Sepsis. — In  considering  the  symptomatology 
of  septic  constitutional  states  it  may  be  well  to  distinguish  between 
those  clinical  entities  designated  as  septicemia  and  j^ysemia.  In  septi- 
cgemia  the  fever  curve,  which  may  begin  without  an  initial  chill,  grad- 
ually rises  almost  without  vacillation  until  it  is  arrested  within  the 
thermic  range  of  life,  or  else  until  it  passes  that  point  and  death  ensues. 
Those  cases  in  which  the  system  has  sustained  injury,  such  as  stran- 
gulated hernia  or  gunshot  wounds  of  the  abdomen,  and,  where  death  is 
said  to  be  due  to  septicaemia,  in  which  the  temperature  has  been  under 
rather  than  above  the  normal  line,  are  to  be  classed  as  cases  of  shock 
rather  than  of  septicaemia.  Prostration,  headache,  anorexia,  with  lassi- 
tude and  stupor,  supervene.  Diarrhoea  is  common;  lymphatic  engorge- 
ment is  generally  detectable;  the  skin  is  pale  and  sometimes  reveals  a 
slight  scarlet  eruption.  The  skin  in  the  earlier  stages  is  parched,  but 
later  the  perspiration  becomes  active,  with  increasing  sallowness  of 
complexion,  increasing  listlessness,  increasing  weakness  and  rapidity 
of  the  pulse,  and  diminished  urinary  secretion;  from  the  initial  chill, 
through  the  whole  course  of  the  disease,  the  pulse  shows  increased 
frequency  with  diminished  force,  until  it  disappears  at  the  wrist;  de- 
lirium obtunds  the  consciousness  until  coma  merges  the  patient  into 
death.  In  pyaemia  the  symptoms  do  not  set  in  so  speedily  after  opera- 
tion, generally  not  until  the  second  week.  They  begin  with  a  chill  fol- 
lowed by  sudden  rise  in  the  temperature  line.  The  subsequent  course 
of  the  disease  is  characterized  by  a  repetition  of  the  chills,  followed  in 
each  instance  by  a  rise  of  temperature.  The  periodicity  between  these 
exacerbations  is  characterized  by  marked  irregularity.  The  fall,  how- 
ever, rarely  if  ever  reaches  the  normal  line.  About  this  time  meta- 
static abscesses  manifest  themselves.  These  may  occur  in  the  subcu- 
taneous connective  tissue  in  some  superficial  lymphatic  in  the  neck 
or  groin;  purulent  effusions  into  the  pleura  or  into  the  joints  may 
occur.  The  parotid  and  other  glands  are  liable  to  infection.  The  mind, 
however,  generally  remains  clear,  and  in  those  patients  who  go  to  a 
fatal  #termination,  death  seems  to  supervene  upon  ^progressive  ex- 
haustion which  finds  its  climax  in  arrest  of  the  cardiac  function. 

Treatment  of  General  Sepsis. — In  the  management  of  general  sep- 
sis the  treatment  is  essentially  antiseptic.  (For  preventive  treatment 
see  Antisepsis.)  In  septicasmia  immediately  following  abdominal  sec- 
tion but  little  good  can  be  accomplished  by  reopening  the  abdo- 
men, although  cases  have  improved  following  this  treatment.  When 
the  abdomen  is  reopened,  in  those  cases  in  which  a  discriminating 
judgment  prompts  the  operation  the  peritoneum  should  be  thoroughly 
washed  with  a  normal  saline  soliTtion  and  a  drainage  tube  should  be  in- 
serted. The  constitutional  state  should  be  combated  by  supportives. 
The  early  occurrence  of  vomiting,  however,  and  its  persistence  will 
generally  interfere  with  the  administration  either  of  remedies  or  nutri- 
tion by  way  of  the  stomach.  Eectal  alimentation  should,  therefore,  be 
resorted  to;  when  the  stomach  will  permit  of  their  exhibition,  copious 


SEPSIS  59 

quantities  of  stimulants  should  be  given.  Heart  stimulants,  such  as 
strychnine,  digitalis,  and,  in  later  stages,  nitroglycerine,  are  of  value. 
Normal  salt  solution,  given  either  by  hypodermoclysis  or  by  intraven- 
ous injection,  has  been  observed  to  furnish  a  needed  volume  to  the 
circulation  and  to  re-enforce  the  patient's  strength.  The  various  anti- 
toxic serums  have  not  yet  yielded  the  benefit  that  it  was  hoped  would  be 
derived  from  their  employment,  the  theoretic  explanation  of  the  diffi- 
culty being  that,  whereas  the  serum  was  derived  from  the  cultures  of 
individual  varieties  of  bacteria,  infections  are  generally  of  the  mixed 
variety,  in  the  presence  of  which  the  special  serum  is  relatively 
powerless. 


CHAPTER    VIII 

ANTISEPSIS 

Antiseptic  provisions  of  Nature — Sterilization:  (a)  Mechanical  means,  (&)  heat,  (c) 
germicidal  agents — The  nurse — The  room — The  patient — Instruments  and 
dressings — Sutures  and  ligatures — Post-operative  antisepsis — The  surgeon: 
Hand  sterilization;  gloves. 

Antiseptic  Provisions  of  Nature. — The  word  antisepsis,  as  previous- 
ly defined,  implies  any  provision  or  procedure  for  limiting  or  stopping- 
putrefaction  or  for  destroying  putrefactive  germs.  Nature  herself  has 
provided  a  double  protection  against  invasion  by  pathogenic  micro- 
organisms. The  first  of  these  provisions  is  expressed  in  what  has  come 
to  be  recognised  as  the  law  of  AVyssakovitsch — viz.:  that  the  epithelial 
cells  covering  any  part  of  the  body,  while  they  maintain  their  integrity, 
protect  the  underlying  structures  and  the  general  system  against  bac- 
terial invasion.  The  second  of  Nature's  effective  provisions  is  expressed 
in  the  law  of  Metschnikoff — viz.:  that  in  the  presence  of  bacterial  in- 
vasion the  leucocytes,  both  uninuclear  and  multinuclear,  acting  as 
phagocytes,  attack  and  destroy  the  invading  micro-organisms.  All 
bacterial  invasions  of  the  body,  therefore,  can  be  said  to  take  place 
only  in  the  presence  of  an  infection  atrium,  which  implies  the  destruc- 
tion of  a  greater  or  less  area  of  protective  epithelium;  and  systemic 
contamination  can  not  result  until  the  invading  bacteria,  like  a  numer- 
ous army,  has  assailed  and  overcome  the  defending  leucocytes.  When, 
however,  it  is  deliberately  intended  to  make  an  infection  atrium  in  the 
form  of  a  surgical  incision,  and  when  it  is  contemplated  thereby  to 
establish  circumstances  so  favourable  to  infection  that  the  defending 
leucocytes  luust  necessarily  be  overpowered,  it  becomes  imperative  to 
practise  those  safeguards  which  are  conventionally  designated  by  the 
word  antisepsis.  They  embrace  various  methods  of  destroying  micro- 
organisms which  are  known  to  exist  upon  the  hands  of  the  surgeon 
or  his  assistants  and  upon  or  within  the  integument  of  the  patient;  that 
cling  to  instruments;  that  infest  materials  utilized  for  sponges  and 
dressings;  or  that  exist  in  great  abundance  in  the  clothing  and  imme- 
diate surroundings  of  the  patient. 

Sterilization,  by  which  is  implied  destruction  of  micro-organisms 
in  a  given  area  or  substance,  is  effected  by  (a)  mechanical  means,  (&) 
heat,  generally  combined  with  pressure,  and  (c)  chemical  agents. 
60 


ANTISEPSIS  61 

Mechanical  sterilization  is  practised  by  careful  and  prolonged  wash- 
ing with  a  detergent,  and  by  heavy  friction.  Soap  is  the  best  detergent, 
but  care  should  be  taken  that  it  is  not  itself  contaminated.  Frequent 
researches  have  shown  that  soap  may  be  thoroughly  infested  with  bac- 
teria. The  danger  from  this  source  can  be  overcome  by  taking  either 
the  ordinary  lye  soap  of  the  kitchen  or  the  laundry,  or,  preferably,  a 
known  variety  of  pure  soap,  such  as  the  ivory,  diluting  it  with  water, 
and  boiling  it  for  twenty  minutes.  This  insures  resterilization, 
should  the  soap  have  previously  become  contaminated.  Brushes  made 
of  vegetable  fibre  are  the  best.  (See  Sterilization  of  the  Hands.)  Gauze 
material,  purchased  for  use  as  sponges  or  dressing,  particularly  cheese 
cloth  as  obtained  in  the  stores,  contains  starch;  it  should,  there- 
fore, be  washed  carefully  with  soap  as  above  prepared,  and  after  being 
rinsed  through  sterilized  water  should  be  dried.  This  can  be  done  either 
before  or  after  the  material  has  been  made  into  the  individual  sponges 
or  dressings,  but  in  either  event  they  must  be  subjected  to  resterilization 
before  being  used.  (See  Sterilization  of  Instruments  and  Dressings.) 
Filters,  such  as  the  Pasteur-Chamberlain,  are  of  doubtful  efficacy  in 
separating  micro-organisms  from  the  water  that  passes  through  them. 

Sterilization  by  Heat. — Heat  is  utilized  for  the  purpose  of  steriliza- 
tion in  the  form  of  both  dry  heat  and  moist  heat  and  in  the  form  of 
heat  combined  with  pressure.  Heat  by  itself,  whether  dry  or  moist, 
is  sufficient  if  applied  in  high  enough  degree,  to  destroy  bacteria,  but 
it  is  not  practicable  at  the  same  time  to  destroy  the  spores  frequently 
given  off  by  the  micro-organisms.  To  destroy  the  spores  at  the  same 
time  that  the  bacteria  are  killed,  it  is  generally  necessary  to  employ 
heat  under  pressure.  The  germicidal  property  of  heat  depends  upon 
the  fact  that  all  micro-organisms  have  a  thermal  death  point  varying 
from  52°  C.  (125.6°  F.)  to  61°  C.  (147.2°  F.).  It  is  not  necessary  in  this 
connection  to  study  the  powers  of  resistance  to  heat  possessed  by  dif- 
ferent bacteria;  but  it  is  sufficient  for  practical  purposes  to  rely  upon 
the  fact  that  exposure  to  a  boiling  temperature  for  ten  minutes  "  will 
infallibly  destroy  all  micro-organisms  in  the  absence  of  spores  when 
they  are  in  a  moist  condition  or  moist  heat  is  used."  (Sternberg.) 
Spores,  however,  have  greater  powers  of  resistance,  and  some  of  them 
are  not  destroyed  even  after  exposure  for  several  hours  to  a  boiling 
temperature.  To  destroy  these  reproductive  bodies  recourse  is  had 
either  to  interrupted  sterilization — i.  e.,  resterilization  after  twenty- 
four  hours — or  to  a  single  sterilization  under  pressure.  The  latter 
method  is  generally  employed  in  America,  and  consists  in  introducing 
the  objects  to  be  sterilized  into  a  steam  chamber  into  which  steam  is 
projected  until  a  pressure  of  at  least  forty  pounds  is  reached.  The 
sterilizer  devised  by  Col.  John  Fehrenbatch  (Fig.  22)  and  used  in  the 
(/incinriati  TTospital,  consists  essentially  of  a  cylinder  surrounding  a 
sterilizing  chamber,  the  double  wall  of  which  incloses  a  space  (//,  II, 
Figs.  23  and  24)  half  an  inch  across.  Steam  is  forced  into  this  hol- 
low space  at  a  pressure  of  fifty  pounds  per  square  inch — ten  pounds 


62 


A  TEXT-BOOK  OF   GYNECOLOGY 


greater  than  that  used  in  the  sterilizing  chamber — which  keeps  the 
Avails  at  a  temperatiire  from  six  to  ten  degrees  higher  than  that  inside. 
This  prevents  a   condensation   of   steam  hy  the   walls   and,   together 

with  an  arrangement  hy 
which  the  steam  is  pre- 
vented from  coming  into 
contact  with  the  dress- 
ings until  it  has  trav- 
ersed the  whole  space 
between  the  two  cylin- 
ders, makes  it  unneces- 
sary to  dry  the  dress- 
ings before  use. 

The  wire  receiving 
basket  is  supported  by 
flanges  {K,  K,  Fig.  34), 
which  keep  it  away  from 
the  walls  of  the  cham- 
ber, allowing  the  steam 
to  penetrate  freely  from 
all  sides,  and  it  has  been 
found  that  the  tempera- 
ture at  the  centre  of  a 
tightly  wound  package 
twelve  inches  in  diame- 
ter is  the  same  as  that 
on  the  outside  of  the 
package. 

Any  desired  pressure, 
up  to  one  hundred 
pounds,  can  be  main- 
tained by  an  invisible,  automatic  arrangement  while  the  steam  is  kept 
in  constant  circulation  at  the  same  time.  The  mechanism  for  closing 
the  head  makes  it  possible  to  secure  a  steam-tight  joint  in  three  sec- 
onds, the  whole  process  of  thorough  sterilization  consuming  about 
fifteen  minutes. 

All  dressings,  sponges,  operation  gowns,  etc.,  should  be  sterilized, 
when  practicable,  by  this  means,  while  instruments  should  be  boiled 
for  ten  miniTtes  in  water  containing  two  drachms  of  powdered  car- 
bonate of  sodium  to  a  quart  of  water.  This  solution  has  the  double 
advantage  of  dissolving  the  capsule,  which  acts  as  a  protective  to  some 
germs,  and  of  keeping  the  instruments  from  rusting.  (See  Steriliza- 
tion of  Dressings  and  Instruments.)  Dry  heat,  involving,  as  it  does, 
the  desiccation  of  the  micro-organisms,  must  be  carried  to  a  higher 
degree  than  is  the  case  with  moist  heat.  The  temperature  of  140°  C. 
(284°  F.),  maintained  for  three  hours,  is  required  to  destroy  the  spores 
of  bacteria. 


Fig.  22.- 


-"  The  sterilizer  devised  by  Col.  John  Feliren- 
batch." — Eeed  (page  fil). 


ANTISEPSIS 


03 


Fig.  23.  — "The  sterilizer  de- 
vised by  Col.  John  Fehren- 
batch  .  .  .  consists  essential- 
ly of  a  cylinder  surrounding 
a  sterilizing  chamber,  the 
double  wall  of  which  in- 
closes a  space  half  an  inch 
across." — Eeed  (page  61). 


Fig.  24. — "  The  wire  receiv- 
ing basket  is  supported 
by  flanges  which  keep 
it  away  from  the  walls 
of  the  chamber,  allowing 
the  steam  to  penetrate 
freely  from  all  sides." — 
Eeed  (page  61). 


Sterilization  by  Germicidal  Agents. — Various  salts,  essential  oils,  and 
gases,  have  the  iDroperty  of  destroying  bacteria.  The  germicidal  prop- 
erty of  these  different  agents  presents  the  widest  range  of  variation. 

Those  of  the  greatest  value,  mentioned  in 
the  order  of  their  germicidal  power,  are 
mercuric  iodide,  silver  iodide,  hydrogen  per- 
oxide, mercuric  chloride,  silver  nitrate,  chlo- 
rine, iodine,  bromine,  carbolic  acid,  potas- 
sium permanganate.  __ 
Some  agents  that 
have  the  highest  ger- 
micidal power  are  of 
no  practical  value  in 
surgery,  because  they 
destroy  the  tissues 
with  which  they  are 
brought  into  contact. 
For  practical  pur- 
poses lysol  or  car- 
bolic acid  in  a  two- 
per-cent  solution,  or 
the  mercuric  chloride 
(1  to  2,000),  is  all 
that  is  required. 
Peroxide  of  hydrogen  is  of  value  in  removing  possible  infection  from 
exposed  tissue  areas.  Among  the  various  detergent  agents  it  is  de- 
sirable to  select  those  which  have  germicidal  properties,  such  as  tur- 
pentine, the  oil  of  cedar,  or  alcohol.  For  dressings,  boric  acid,  iodo- 
form, and  aristol,  have  a  demonstrated  value;  although  in  aseptic 
wounds  with  accurate  coaptation  of  the  margins,  antiseptic  agents  are 
not  generally  required,  the  protective  influence  of  the  leucocytes  and 
of  the  carefully  adjusted  sterilized  dressing  subserving  all  purposes 
against  infection. 

The  Nurse. — Those  measures  which  are  devised  and  practised  for 
the  prevention  of  sepsis,  and  which  contemplate  the  sterilization  of  the 
hands  of  the  surgeon  and  attendants  and  of  the  field  of  operation,  of 
sponges,  dressings,  and  instruments,  as  well  as  of  the  patient's  imme- 
diate environment,  involve  the  exercise  of  so  much  special  knowledge 
and  skill  that  they  must  be  intrusted  to  a  person  of  special  training. 
In  recognition  of  this  fact,  the  leading  hospitals  of  the  world  have 
been  engaged  during  the  past  fifteen  years  in  giving  special  courses 
of  instruction  and  training  to  that  class  of  women  who  have  come  to 
be  known  as  graduate  nurses.  The  services  of  the  trained,  or  more 
properly  the  graduate  nurse,  are  essential  to  the  successful  practise  of 
aseptic  surgery.  8he  should  be  the  possessor  of  bodily  vigour,  prefer- 
ably comely,  of  pleasant  address,  with  an  interest  in  her  work,  prompted 
both  by  a  love  of  humanity  and  pride  in  her  profession.    Such  a  person 


Q4,  A  TEXT-BOOK  OF   GYNECOLOGY 

in  these  latter  days  is  thoroughly  familiar  with  sepsis,  its  cause  and  pre- 
vention, as  well  as  with  surgical  technique.  With  a  mere  statement  of 
the  operation  intended,  she  may  be  left  without  further  instruction 
to  the  jjreparation  of  the  case  and  its  surroundings.  The  nurse  should 
always  be  equipped  with  not  less  than  three  uniforms,  a  number  of 
aprons,  catheters,  rectal  tubes,  syringes,  thermometer,  and  hypodermic 
syringe,  the  last  named  being  the  one  article  which  can  best  be  spared 
from  her  armamentarium.  She  should  always  have  a  plentiful  supply  of 
antiseptic  tablets.  She  should  also  provide  herself  with  record  blanks 
and  should  keep  a  careful  record  of  every  essential  fact  relating  to  the 
preparation  or  the  progress  of  the  case. 

The  Eoom. — It  is  always  more  desirable  to  operate  in  a  well-con- 
ducted hospital,  although  any  residence  is  a  safer  place  for  surgical 
work  than  is  a  poor  hospital.  In  hospitals  the  operating  room  may  be 
said  to  be  the  distinguishing  feature.  It  is  an  apartment  set  aside 
exclusively  for  operations,  and  is  constructed  of  impervious  and  thor- 
oughly washable  walls,  floors,  and  ceilings.  It  is  arranged  with  refer- 
ence, to  satisfactory  light,  proper  drainage,  and  the  maintenance  of  a 
high  and  equable  temj)erature.  It  is  furnished  with  only  sterilizable 
furniture  and  fixtures,  consisting  of  glass-topped  enameled  tables  upon 
which  to  place  the  patient,  the  instruments,  sponges,  etc.  Incandescent 
lights  are  so  arranged  that  the  field  of  operation  can  be  illuminated  by 
that  means,  if  required  by  circumstances  of  emergency.  The  ojjera- 
ting  room  is  sometimes  constructed  to  contain  the  sterilizing  apparatus, 
but  this  is  better  done  in  an  adjoining  apartment,  specially  furnished 
and  otherwise  adapted  for  the  purpose.  It  is  desirable  also  to  prepare 
the  patient  in  an  apartment  adjacent  to  the  oj^erating  room  and  con- 
taining special  appliances  for  the  purpose.  In  private  residences  an 
effort  should  be  made  to  reproduce  as  nearly  as  possible  the  more  ideal 
conditions  of  the  hospital.  The  circumstances  of  the  ordinary  home, 
however,  are  all  adverse  to  this  realization,  and  enjoin  upon  the  nurse 
the  most  serious  responsibility  in  overcoming  them.  She  should  begin 
by  having  all  furniture,  including  pictures  and  hangings,  taken  from 
the  room;  the  walls,  floors,  and  ceilings,  should  then  be  carefully  wiped 
with  a  moist  bichloride  cloth,  after  which  the  floors,  Avindows,  and 
especially  the  doors  and  door  knobs,  should  be  scrubbed  with  a  1-to- 
2,000  bichloride  solution.  Each  article  of  furniture  that  is  thereafter 
brought  into  the  room  should  be  cleaned  as  thoroughly  as  possible 
before  it  is  returned,  and  again  gone  over  with  a  bichloride  cloth  after 
being  brought  in.  The  most  important  article  of  furniture  to  be  con- 
sidered in  this  connection  is  the  operating  table.  In  the  absence  of  a 
special  table,  one  answering  the  purpose  very  well  can  be  extemporized 
by  utilizing  an  extension  table  such  as  is  found  in  practically  every 
dining  room.  This  should  be  thoroughly  scrubbed  before  it  is  brought 
to  the  operating  room,  and  it  should  be  set  up  by  extending  it  a  dis- 
tance of  about  2-J  feet,  and  by  taking  two  of  the  boards,  or  leaves,  ordi- 
narily used  in  the  table,  and  placing  them  lengthwise  upon  the  top, 


ANTISEPSIS 


65 


tlieir  ends  resting  upon  the  no^v^  extended  ends  of  the  tahle.  A  blanket, 
folded  lengthwise,  can  now  be  placed  over  these  boards,  but  ex- 
tending the  whole  length  of  the  taljle.  Above  this  should  be  placed 
some  protective  material,  such  as  oilcloth  rubber  sheeting,  or,  in  the 
absence  of  anything  better,  a  number  of  newspapers,  and  over  all  a 
sterilized  sheet.  Sterilized  towels  may  be  placed  over  the  corners  of 
the  table  between  which,  upon  opposite  sides,  will  stand  the  surgeon  and 
his  assistant.  This  arrangement  makes  a  really  convenient  operating 
table,  and  one  that  is  not  too  broad.  Another  kind  of  table,  easily  ex- 
temporized by  a  carpenter  or  a  handy  man  about  the  place,  consists  of 
two  trestles,  32  inches  high  and  about  18  inches  wide.  On  these  is 
placed  a  board  from  12  to  18  inches  in  width;  on  this  board  is  placed 
another  and  shorter  one,  bevelled  at  one  end  and  surrounded  at  the 
other  by  a  piece  of  iron  fastened  midway  in  the  edge  upon  either  side  by 
screws.  The  bevelled  edge  of  this  board,  resting  against  two  screws  set 
in  the  lower  board,  and  elevated  at  the  other  end,  will  be  supported  by 
this  iron  brace,  resting  against  some  screwheads,  thus  making  a  very  de- 
sirable and  convenient  Trendelenburg  attachment  (Fig.  25).     Smaller 


Fig.  i!5. — "A  very  desiraVjle  and  convenient  Trendelenburg  attachment." — Reed. 


tables  or  stands  should  be  provided  for  bowls,  instruments,  etc.  At 
least  four  wash  bowls  should  be  provided  and  a  dozen  or  more  towels. 
Two  pitchers,  one  containing  hot  and  the  other  cold  sterilized  water, 
and  tv\'o  larger  receptacles  for  a  reserve  supply  of  hot  and  cold  water, 
slioiiM  b(;  provided.    One  wash  ])o\vl  should  be;  used  for  the  preliminary 


66  A   TEXT-BOOK  OF   GYNECOLOGY 

ablution  of  the  hands,  the  other  should  contain  some  alcohol,  and  a 
third  the  bichloride  solution.  The  room  should  be  maintained  at  a 
temperature  of  about  85°  F. 

The  Patient. — The  patient  having-  been  given  the  preliminary  laxa- 
tive and  general  bath  described  more  in  detail  in  the  chapter  on  Ab- 
dominal Section,  is  divested  of  her  clothing  and  is  placed  between  ster- 
ilized sheets.  If  she  is  able  to  take  a  general  bath  in  a  tub  as  an  inter- 
mediate step,  so  much  the  better;  but  if  she  is  not  able  to  do  this  she 
should  be  given  a  general  sponge  bath,  care  being  taken  to  avoid  chill- 
ing her.  After  the  general  bath  the  pubes  and  pudendum  should  be 
shaved.  They  are  then  rinsed  thoroughly  Avith  soap  and  water.  The 
patient  is  next  given  a  careful  vaginal  douche  consisting  first  of  clear 
water;  while  this  douche  is  in  progress  the  nurse  should  insert  into 
the  vagina  some  soap,  and  with  her  finger  thoroughly  wash  the  vaginal 
walls  up  to  the  uterine  juncture.  After  a  half  gallon  of  plain  hot  water 
has  been  used  in  the  douche  the  vagina  should  be  irrigated  with  a  hot 
bichloride  solution  (1  to  2,000).  The  abdomen  should  then  be  exposed 
and  thoroughly  soaped.  The  skin  should  be  vigorously  scrubbed  for 
ten  minutes  with  a  brush.  This  is  a  manipulation  the  proper  per- 
formance of  which  requires  judgment  on  the  part  of  the  nurse.  A 
nurse  who  does  not  understand  her  business  will  simjDly  follow  direc- 
tions to  the  letter  and  will  scrub  the  skin  with  a  rough  brush  for  ten 
minutes  regardless  of  consequences.  It  is  important  to  remember 
that  undue  pressure  is  unnecessary  for  the  jDrojier  cleansing  of  the 
skin,  and  is  liable  to  do  damage  to  the  internal  infiamed  organs; 
while  pressure  which  is  too  vigorous  will  rub  off  patches  of  epithelium. 
This  should  be  carefully  avoided,  as  every  area  of  abrasion  may  be- 
come an  infection  atrium.  After  thoroughly  washing  the  abdominal 
wall,  any  remaining  fatty  material  should  be  removed  by  the  use  of 
either  ether  or  alcohol.  The  alcohol  should  be  clean  and  fresh.  The 
solution  of  mercuric  bichloride  (1  to  2,000)  should  then  be  applied, 
first  in  the  form  of  an  ablution,  and  finally  in  the  form  of  a  pack, 
consisting  of  a  towel  saturated  with  the  bichloride  solution,  cov- 
ered with  other  toAvels,  and  kept  in  position  by  a  retaining  bandage.  In 
cases  of  operation  upon  the  perineum  or  the  vagina  practically  the  same 
precautions  should  be  taken  with  regard  to  the  pudendal  integument. 
The  final  moist  dressings,  comprising  the  last  step  in  the  process  of 
sterilization,  should  be  kept  in  position  until  the  patient  is  placed  upon 
the  operating  table.  The  nurse  with  her  own  hands,  previously  re- 
sterilized,  then  removes  the  preparatory  dressings,  and  again  washes 
the  abdomen  with  alcohol,  followed  by  the  bi<3hloride  solution.  All 
of  the  bichloride  solution  thus  used  should  be  carefully  absorbed  by 
sterilized  sponges;  otherwise,  by  remaining  upon  the  surface  of  the 
abdomen,  it  is  brought  in  contact  with  the  surgeon's  blade  to  the  almost 
instant  ruin  of  its  edge. 

Instruments  and  Dressings. — Sponges  are  biit  rarely  used  in  abdom- 
inal and  pelvic  surgery,  the  preference  being  given  to  small  pieces  of 


ANTISEPSIS  07 

gauze,  which  after  being  used  to  absorb  blood  or  discharges  are  instant- 
ly thrown  away.  There  is  no  doubt  that  this  change  has  marked  a 
distinct  advance  in  aseptic  surgery.  Dressings  are  made  of  the  same 
material.  In  hospitals  both  sponges  and  dressings  of  gauze  are  made 
in  large  quantities  and  are  sterilized  by  washing  (see  Mechanical  Ster- 
ilization) and  by  being  subjected  to  heat  under  pressure  in  a  steam 
sterilizer.  In  private  practice  it  is  better  to  secure  a  bundle  of  sponges 
and  dressings  that  have  been  thus  sterilized,  but  when  this  is  not  prac- 
ticable, it  is  better,  after  washing,  boiling,  and  drying  the  material,  to 
make  it  up  into  sponges  and  dressings,  which  are  then  to  be  resterilized 
in  a  bundle  by  putting  them  into  the  oven  of  the  kitchen  stove,  where 
they  are  permitted  to  bake  until  the  outer  covering  is  thoroughly 
scorched,  the  heat  having  been  maintained  for  not  less  than  half 
an  hour. 

Sutures  and  Ligatures. — Sutures  are  used  to  approximate  margins 
of  a  wound,  and  consist  usually  of  silk,  catgut,  silkworm  gut,  silver 
wire,  or  iron  wire.  These  materials  are  all  now  susceptible  of  being 
sterilized  by  heat,  with  the  exception  of  catgut;  simple  boiling  in  plain 
water  will  answer  the  purpose.  Ligatures  are  used  for  hemostatic  pur- 
poses and  consist  of  silk  and  catgut. 

Catgut,  as  known  to  commerce,  is  prepared  from  the  intestine  of 
the  sheep,  and  its  use  in  surgery  has  been  designated  by  Nus.gbaum  as 
Lister's  greatest  discovery.  It  has  the  advantages  of  being  strong, 
flexible  enough  to  be  tied  into  a  safe  knot,  capable  of  complete  steril- 
ization, and  completely  absorbable  when  left  either  within  the  perito- 
neal cavity  or  the  parietal  structures.  Since  the  secret  of  its  steriliza- 
tion has  been  discovered,  it  possesses  no  disadvantages  that  are  worthy 
of  consideration.  It  was  formerly  looked  upon  as  a  fertile  culture  medi- 
um when  left  in  tissues  that  were  previously  the  seat  of  infection;  it 
was  justly  recognised  as  being  difficult  of  sterilization;  and  it  was  urged 
against  it  that  it  was  liable  to  become  absorbed  too  soon.  With  Hof- 
meister's  formula,  however,  all  these  objections  are  at  an  end.  This 
formula,  which  has  been  popularized  in  America  through  the  influence 
of  Nicholas  Senn  {Medical  Mirror,  January,  1897),  is  given  by  him  as 
follows:  "  (1)  The  catgut  is  wound  on  a  glass  plate  with  slightly  pro- 
jecting edges,  so  that  the  gut  is  free  from  the  sides  of  the  plate  and  ex- 
posed to  the  circulation  of  the  boiling  and  flowing  water.  The  ends  of 
the  gut  are  fastened  through  holes  in  the  plate.  (3)  Immersion  twelve 
to  forty-eight  hours  in  aqueous  solution  of  formalin,  two  to  four  per 
cent.  (3)  Immersion  in  flowing  water  at  least  twelve  hours,  to  free  the 
gut  from  the  formalin.  (4)  Boiling  in  water  from  ten  to  thirty  minutes. 
1'en  to  twelve  minutes  is  amply  sufficient,  as  all  microbes  and  spores  are 
killed  by  exposure  to  boiling  heat  for  that  length  of  time.  (5)  Harden- 
ing and  preservation  in  absolute  alcohol  containing  five  per  cent  of 
glycerine  and  one  tenth  of  one  per  cent  of  corrosive  sublimate."  Senn 
modifies  the  above  formula  by  boiling  the  deformalinized  catgut  from 
twelve  to  fifteen  minutes,  after  wliieli  it  is  cut  into  pieces  of  desirable 


e,S  A  TEXT-BOOK  OF   GYNECOLOGY 

length,  and  tied  into  small  bundles  containing  from  6  to  12  threads, 
^vhich  are  immersed  and  kept  ready  for  use  in  the  following  mixture: 
Absolute  alcohol,  950;  glycerine,  50;  finely  pulverized  iodoform,  100. 
The  alcohol  dissolves  part  of  the  iodoform,  which  is  presumed  to  add  to 
the  antiseptic  value  of  the  solution.  Senn  states  that  iodoform  applied 
to  recent  wounds  diminishes  the  amount  of  primary  wound  secretion. 
This,  however,  is  contrary  to  the  experience  of  Eeed,  who  has  found 
less  wound  secretion  from  catgut  prepared  according  to  Hofmeister's 
formula,  but  preserved  in  Senn's  fluid  with  iodoform  left  out.  The 
absolute  alcohol  of  itself  is  a  safe  precaution  against  the  infection  of 
the  catgut.  Goldspohn  has  had  satisfactory  results  from  catgut  which, 
after  being  prepared  by  the  Hofmeister  formula  and  deformalinized  in 
running  water  for  forty-eight  hours,  was  boiled  for  twenty  minutes  in  a 
l-to-1,000  solution  of  pyoctanin  in  water,  the  excess  of  pyoctanin  being 
washed  out  and  the  catgut  preserved  in  plain  alcohol.  The  tendon  from 
the  kangaroo's  tail  has  been  introduced  into  America,  while  those 
derived  from  the  legs  of  the  reindeer  (ostiakes)  have  been  used  in 
Eussia.  They  are  very  strong  and  slow  of  absorption,  and  seem  to 
have  had  a  special  claim  for  consideration  as  sutures  in  operations  for 
hernia,  etc.,  in  which  it  is  desirable  to  maintain  their  retentive  power  as 
long  as  possible.  The  present  method  of  preparing  catgut,  its  cheap- 
ness, and  general  desirability,  however,  leave  no  excuse  for  the  con- 
tinued employment  of  tendons  as  either  ligatures  or  sutures. 

Post-operative  Antisepsis. — In  the  presence  of  an  aseptic  wound 
there  is  nothing  to  do  but  to  restrain  the  curiosity.  Where  there  is  no 
febrile  reaction,  no  pain  in  the  wound,  no  pulsation  in  the  seat  of  oper- 
ation, it  is  safe  to  leave  the  A\'ound  alone  until  the  eighth  day.  If 
buried  animal  sutures  have  been  employed,  the  dressings  can  be  left 
on  with  saftey  from  ten  to  fourteen  days.  If,  however,  interrupted 
nonabsorbable  sutures  have  been  employed,  the  dressings  should  be 
taken  down  not  later  than  the  eighth  day  with  the  object  of  removing 
any  sutures  that  may  threaten  to  do  mischief.  A'^Hien,  however,  the 
patient  has  fever  and  complains  of  pain  and  throbbing  in  the  wound, 
which  shows  a  tendency  to  increase  rather  than  to  subside,  the  dress- 
ings should  be  taken  down  and  the  wound  should  be  reopened  at  any 
point  that  may  be  indicated  by  redness  or  tension.  Pus  will  thus  be 
revealed.  When  this  occurs,  particularly  in  a  hospital,  it  should  be 
accepted  as  a  circumstance  of  serious  importance,  threatening  alike  the 
lives  of  other  inmates  and  the  reputation  and  usefulness  of  the  insti- 
tution itself.  A  pus  case  may  be  the  focus  of  an  infection  that,  in  the 
absence  of  an  intelligent  discipline  thoroughly  enforced,  may  result  in 
the  infection  of  the  entire  institution.  More  than  one  hospital  is  thus 
thoroughly  infected,  the  surgeons  in  charge  wondering  why  they  can 
no  longer  secure  aseptic  results.  The  micro-organisms  of  pus  are  hid- 
den foes  that  may  lurk  anywhere  that  can  be  touched  by  infected  hands, 
to  be  carried  thence  by  other  hands  to  infect  yet  uninfected  fields.  To 
avoid  this  calamity,  a  pus  case  should  be  isolated  by  being  put  into  a 


ANTISEPSIS  (]9 

room  by  itself  in  charge  of  a  special  nurse,  under  the  care  of  a  special 
interne,  neither  of  whom  should  be  allowed  to  come  in  contact  with 
noninfected  cases.  Dressings  should  be  removed  with  the  utmost  care 
to  protect  the  bedclothing  and  the  patient's  garments,  to  say  nothing  of 
the  nurse's  hands,  from  contamination.  Long  dressing  forceps  should 
be  used,  and  dressings  or  sponges  employed  in  the  course  of  the  case 
should  be  deposited  in  a  large  granite  basin. 

The  Surgeon. — The  antiseptic  precautions  to  be  observed  by  the 
surgeon  devolve  with  equal  force  upon  his  assistants,  including  the 
nurse.  The  surgeon,  to  begin  with,  should  possess  the  instinct  of  clean- 
liness, or  else  he  should  be  deprived  of  his  license  to  practise.  The  suc- 
cess of  the  surgeon  in  aseptic  surgery  is  directly  proportionate  to  the 
extent  to  which  he  possesses  this  instinct  and  is  actuated  by  it;  it  must 
be  the  dominating  impulse  of  his  work,  and  no  amount  of  technical 
training  can  entirely  make  up  for  its  absence.  Important  as  is  this  in- 
stinct, it  needs  to  be  directed  by  intelligence  and  crystallized  into 
habit.  The  discipline  necessary  for  this  purpose  is  a  severe  one.  It 
has  its  beginning  in  habits  of  personal  cleanliness,  including  frequent 
bathing,  repeated  ablutions  of  the  hands,  and  painstaking  supervision 
of  the  finger  nails;  but  the  exactions  of  surgical  asepsis  reqiiire  even 
more  than  this. 

Hand  sterilization  has  been,  and  remains,  one  of  the  perplexing 
problems  of  the  new  regime.  The  fact  that  various  micro-organisms, 
notably  the  Bacillus  epidermidis  alhus,  find  their  way  into  the  deeper 
epithelial  folds  of  the  skin,  where  they  are  beyond  the  reach  of  chem- 
ical antisepsis,  has  furnished  the  chief  difficulty.  The  method  of 
hand  sterilization  at  present  practised  by  the  majority  of  surgeons  is 
as  follows:  The  hands  are  soaked  for  a  period  of  twenty  minutes  in 
soapsuds,  made  of  sterilized  soap.  The  ablutions  extend  to  the  elbow 
and  are  associated  with  friction  with  a  stiff  brush,  preferably  of  vege- 
table fibre.  At  the  expiration  of  this  time,  the  water  having  been 
changed  repeatedly,  the  plug  is  taken  from  the  bottom  of  the  wash- 
stand  and  the  hands  and  arms  are  washed  for  another  period  of  five 
minutes  with  a  fresh  sterilized  brush  under  a  stream  of  running 
tepid  water.  The  direction  in  which  the  friction  should  be  applied  is 
of  importance,  it  being  essential  that  the  brush  should  be  moved  in 
the  direction  of  the  cutaneous  folds.  The  hands  are  now  washed  in 
either  ether  or  alcohol,  which  should  be  fresh.  The  habit  of  some 
hospitals  of  saving  alcohol  used  for  hand  washing  is  not  only  of  ques- 
tionable economy,  but  is  a  proceeding  only  a  trifle  less  filthy  than  sav- 
ing wash  water.  After  the  ether  or  alcohol  bath  the  hands  are  rubbed 
for  a  few  minutes  in  a  solution  of  l-to-2,000  mercuric  bichloride. 

Another  method  of  hand  sterilization,  introduced  by  Schatz,  of 
Rostock,  consists  in  the  usual  preliminary  washing,  as  already  de- 
scribed; the  hands  are  then  immersed  for  several  minutes  in  a  saturated 
solution  of  potassium  ponnanganato;  they  are  then  washed  in  a  satu- 
rated s(jliition  of  oxalic  acid,  •di'Utr  which,  cliiefiy  to  remove!  the  yellov/ 


YO  A   TEXT-BOOK  OP   GYNECOLOGY 

staining  induced  by  the  permanganate  and  but  slightly  modified  by  the 
oxalic  acid^  the  hands  are  washed  in  limewater,  or  preferably  in  hydro- 
gen peroxide.  The  hydrogen  peroxide  is  used  by  Warren,  of  Boston, 
and  may  be  said  to  be  the  redeeming  feature  of  the  entire  formula,  as 
it  possesses  not  only  cleansing  but  antiseptic  properties  vastly  in  excess 
of  the  other  ingredients. 

In  cases  in  which  the  hands  have  become  unexpectedly  contami- 
nated by  being  inunersed  in  live  pus,  and  in  which  it  is  necessary  to 
proceed  to  a  succeeding  operation  under  otherwise  aseptic  surround- 
ings, the  question  of  immediate  hand  sterilization  becomes  an  exceed- 
ingly imi^ortant  one.  Under  these  circumstances,  after  carefully  wash- 
ing and  rinsing  the  hands,  they  may  be  bathed  in  ninety-eight  per  cent 
carbolic  acid  for  a  few  seconds.  This  agent  is  naturally  an  escharotic, 
but  the  ej)ithelium  is  sufficient  to  resist  its  action  for  the  brief  time 
involved  in  its  application,  after  which  it  is  thoroughly  neutralized  by 
washing  the  hands  in  pure  alcohol.  Eeed  has  reiDcatedly  adopted  this 
measure  with  satisfactory  results.  Sanger  (C entralhlatt  filr  Chirurgie), 
after  thoroughly  washing  his  hands,  immerses  them  in  a  warm  solution 
of  from  two  to  five  per  cent  of  hydrochloric  acid,  and  then  in  a  one- 
half  to  two-per-cent  solution  of  permanganate  of  potassium.  The  dis- 
coloration thus  produced  is  removed  by  a  bath  of  sulphurous  acid. 
The  chemical  changes  resulting  from  the  contact  with  these  different 
agents  cause,  among  other  things,  the  liberation  of  free  chlorine,  oxygen, 
and  sulphurous-acid  gas,  all  of  which  possess  germicidal  |)roperties  in 
high  degree.  Bacteriological  studies  of  this  method  and  its  results  by 
Kronig  and  Paul  confirm  its  usefulness.  Chlorine  gas  is  a  most  val- 
uable disinfectant  for  the  hands;  and  a  convenient  method  of  its  a|)pli- 
cation,  popularized  by  Weir,  is  to  wash  the  hands  with  a  chloride-of- 
lime  paste  for  a  few  minutes,  subsequently  rinsing  them  in  sterilized 
water.  With  all  of  these  methods,  however,  some  failures  are  reported, 
showing  that  hand  sterilization  by  chemical  means  has  not  attained  per- 
fection. 

To  obviate  the  results  following  on  what  seems  to  be  an  insur- 
mountable difficulty,  the  expedient  has  been  hit  upon  of  operating  with 
covered  hands.  Gloves  have  been  introduced  by  Halstead  and  Mikulicz, 
to  the  latter  of  whom  is  probably  due  the  credit  of  establishing  their  use 
in  a  systematic  way.  Cotton  and  silk  gloves  have  been  used,  but  Lockett 
(Philadelphia  Medical  Journal,  February  11,  1899)  has  demonstrated 
that  permeable  gloves  become  speedily  saturated  with  micro-organisms, 
which  observations  have  been  confirmed  by  Pfahler.  Thin  rubber 
gloves  are  now  made  that  are  impermeable,  that  interfere  but  slightly 
with  sensation,  and  that  are  capable  of  complete  sterilization  by  boiling. 
After  they  have  been  worn  a  few  times  they  seem  to  offer  no  serious 
impediment  to  dexterity.  In  speaking  of  their  use,  Kocher  (Philadel- 
phia Medical  Journal,  June  10,  1899)  advises  as  follows:  "Avoid  touch- 
ing with  uncovered  hands  any  infective  or  septic  material  hetiveen 
the  operations,  or  wash  it  carefully  away  at  once,  cut  your  nails  as  short 


ANTISEPSIS  71 

as  possible^  brush  your  hands  thoroughly  with  hot  water,  soap,  and  alco- 
hol (85  to  95  per  cent),  avoiding  any  poisonous  disinfectant  before  you 
operate,  and,  if  you  wish  to  be  very  careful,  put  on  cotton,  silk,  or,  better 
still,  rubber  gloves  when  you  touch  the  threads  for  ligatures  and  sutures, 
and  when  you  have  to  tear  the  tissues  much  and  to  rub  your  fingers  in 
the  depth  of  a  wound." 

A  pan  filled  with  a  strong  bichloride  solution,  or,  still  better,  a 
paper  receptacle,  such  as  a  cornucopia,  should  be  used  to  receive  the 
soiled  dressings,  receptacle  and  all  being  burned  at  the  conclusion  of 
the  seance. 


■CHAPTER    IX 

SHOCK 

Definition — Pathology — Causes  —  Symptoms  —  Diagnosis — Treatment :    Prophylac- 
tic, restorative. 

Shock  is  an  inliibition,  more  or  less  profound,  of  practically  all  of 
the  vital  functions,  due  to  defective  vasomotor  nerve  control  and  char- 
acterized by  diminished  cardiac  force,  lessened  arterial  tension,  embar- 
rassed respiration,  muscular  relaxation,  the  more  or  less  complete 
arrest  of  glandular  activity,  and  mental  lethargy,  verging  in  the  later 
stages  into  delirium. 

Pathology. — Shock  must  manifestly  be  regarded  as  a  neuro-paral- 
ysis,  in  which  there  is  evident  fatigue  or  exhaustion  of  the  nerve  cen- 
tres, the  result  of  profound  and  generalh'  sudden  irritation  of  some 
part  of  the  svmpathetic  nervous  system.  This  irritation  ma}-  be  phys- 
ical, as  in  the  case  of  a  blow  over  the  solar  plexus,  or  it  may  be  mental, 
as  in  the  frequent  examples  of  intense  fright. 

Causes  of  Shock. — Pain  and  fright,  as  already  indicated,  may  be 
causes  of  shock.  Every  operator  of  extensive  experience  has  seen  cases 
in  which  the  symptoms  of  shock  were  more  pronounced  before  the  oper- 
ation began  than  after  it  was  concluded,  the  cause  evidently  existing 
in  the  extreme  apprehensions  of  the  patient.  In  abdominal  and  pelvic 
surgery,  shock  is  of  such  frequent  occurrence  that  its  causes,  under 
such  circumstances,  are  worth}^  of  special  consideration.  According  to 
the  brilliant  investigations  of  Dr.  George  W.  Crile,  of  Cleveland  {Ameri- 
can Gynecological  and  Obstetrical  Journal,  1898),  which  are  confirmed 
in  practically  every  detail  by  clinical  experience,  we  learn  that,  even 
under  profound  anesthesia,  the  s3Tiiptoms  of  shock  may  be  induced  by 
(a)  opening  the  abdominal  cavity;  (b)  the  mere  exposure  of  the  abdom- 
inal viscera  to  the  atmosphere,  the  profoundness  of  the  shock  varying 
inversely  to  the  temperature  of  the  air;  (c)  manipulation  of  the  peri- 
toneum and  underlying  organs,  the  intensity  of  the  shock  increasing 
as  the  manipulations  extend  from  the  pelvis  to  the  diaphragm;  (d) 
disturbance  of  local  splanchnic  vasomotor  areas;  (e)  pressure  upon 
important  splanchnic  veins,  especially  upon  the  vena  cava;  (f)  hemor- 
rhage to  a  degree  sufficient  to  lessen  circulator}'^  tension.  Phenomena 
of  shock  are  induced  more  readily  in  youth  and  old  age. 

Symptoms  of  Shock. — Shock  is  characterized  by  the  sudden  onset  of 
s}Tnptoms,  the  most  pronounced  of  which  is  general  physical  depres- 


SHOCK  73 

sion.  The  surface  becomes  blanched;  the  features  are  pinched  and 
distorted,  sometimes  beyond  recognition;  the  cutaneous  temperature  is 
lowered;  the  hands  and  fingers  are  shrunken  and  the  nails  are  of  a 
bluish  colour;  the  pulse  becomes  feeble  and  accelerated;  the  respiration 
irregular;  the  muscular  tone  is  diminished;  the  sphincters  frequently 
are  relaxed;  the  patient  becomes  faint,  lethargic,  and  often  drifts  into 
unconsciousness.  In  this  condition  there  is  an  arrest  of  all  secre- 
tory and  excretory  functions.  These  symptoms,  in  the  aggregate,  are 
generally  of  short  duration.  If  they  become  more  intense  they  speed- 
ily terminate  in  death;  if  reaction  sets  in,  the  respiration  improves, 
normal  colour  returns  to  the  skin,  in  which  the  transj)iratory  function 
shows  evidence  of  re-establishment,  the  heart  improves  in  force  and 
rhythm — probably  the  initial  change  in  the  return  to  the  normal  state 
— and  the  mental  functions  resume  their  sway. 

Diagnosis  of  Shock. — The  diagnosis  of  shock  is  made  primarily 
upon  the  consideration  of  the  foregoing  spnptoms.  It  is  important, 
however,  to  distinguish  it  from  several  conditions  with  which  it  is  fre- 
quently confused.  Hemorrhage  presents  many  symptoms  in  common 
with  shock.  In  hemorrhage,  however,  there  occur,  as  distinctive  fea- 
tures, an  anxious  but  intelligent  exjDression  of  the  face;  extreme  rest- 
lessness, manifested  especially  by  tossing  about  of  the  arms;  and  fre- 
quent attacks  of  syncope,  in  the  intervals  between  which  the  patient 
regains  consciousness.  To  the  experienced  and  attentive  observer,  one 
of  the  most  characteristic  s}Tnptoms  of  hemorrhage  is  a  pulse  of  in- 
creasing frequency  with  diminishing  force  and  volume,  imparting  to 
the  sense  of  touch  the  impression  that  the  heart  is  working  without 
appreciable  resistance.  Acute  septic  poisoning  in  its  symptomatology*  is 
often  confused  with  shock.  These  cases  occur  especially  in  abdominal 
surgery,  and  their  proper  diagnosis  depends  upon,  first,  the  fact  that 
they  have  been  preceded  by  circumstances  of,  at  least,  possible  septic 
infection;  next,  the  gradual  development  of  the  symptoms;  and,  thirdly, 
the  temperature  range,  which  in  the  earlier  stages  is  generally  char- 
acteristically vacillating,  but  later  runs  very  high.  In  these  cases  the 
temperature  of  the  surface  may  be  subnormal,  while  that  which  is  regis- 
tered, either  in  the  mouth,  the  rectum,  or  the  vagina,  may  reach  lOi"" 
F.,  or  even  higher.  The  majority  of  cases  of  "  insidious  shock  "  and 
of  "  dela3'ed  shock  "  belong  to  this  class.  Syncope,  or  fainting,  is  re- 
garded by  some  as  a  form  of  shock.  According  to  Warren,  however,  it 
is  to  be  regarded  simply  as  an  acute  cerebral  anaemia,  the  essential  symp- 
toms of  which — ^namely,  preliminary  nausea,  ringing  in  the  ears,  and 
dizziness,  followed  by  a  fainting  fit  during  which  the  patient  is  tem- 
porarily unconscious — distinguish  it  from  shock.  Emboli  of  various 
sorts  produce  s}Tnptoms  analogous  to  shock;  thus,  "Warren  states  that 
acute  suppurations  in  tissues  rich  in  fat  may  produce  fat  emboli,  by 
which  it  is  implied  that  the  fluid  fat  liberated  by  the  suppurative  pro- 
cess may  be  taken  up  by  the  lymphatics  and  carried  by  them  into  the 
circulation.    These  emboli  are  most  frequently  deposited  in  the  lungs. 


74  A   TEXT-BOOK  OF   GYNECOLOGY 

From  this  locus  they  are  generally  reabsorbed  and  distributed  to  vari- 
ous parts  of  the  system.  When  large  amounts  of  the  fat,  however,  accu- 
mulate in  the  lungs,  it  may  induce  alarming  symptoms  or  death.  "  The 
symptoms  of  this  complication,"  says  Warren,  "  which  occurs  within 
twenty-four  or  forty-eight  hours  after  an  injury,  are  sudden  pallor, 
irregular  heart  action,  dyspnoea,  perhaps  hemoptysis,  or  convulsions  and 
death.  Fat  will  be  found  in  the  urine."  Air  embolism  consists  of  the 
introduction  of  air  into  the  veins.  In  small  quantities  air  in  the  veins 
produces  no  injury,  but  when,  according  to  Hare,  a  pint  or  more  of  it 
is  introduced  into  the  circulation,  it  proves  fatal.  Under  these  circum- 
stances the  heart  becomes  filled  with  air  and  can  not  contract,  when 
death,  attended  with  symptoms  of  syncope,  is  instantaneous. 

Treatment  of  Shock. — The  treatment  of  shock  resolves  itself  into 
(a)  prophylactic,  and  (b)  restorative. 

The  prophylactic  treatment  of  shock  should  be  carefully  considered 
in  all  cases  in  which  patients  of  lowered  vitality  are  about  to  be  sub- 
jected to  surgical  operations.  In  such  cases  the  jsrolonged  fasting  and 
violent  catharsis,  frequently  practised  in  preparing  a  patient  for  oper- 
ation, are  calculated  to  still  further  reduce  the  strength  and  should  be 
avoided.  To  such  patients  a  mild  cathartic  may  be  given  with  advan- 
tage, although  in  extreme  instances  it  is  better  to  rely  upon  enemas 
to  evacuate  the  boAvels.  The  usual  fast  j)receding  the  operation  should 
also  be  omitted,  and  the  patient  be  given  a  free  liquid  diet  of  milk, 
if  well  tolerated,  or,  still  better,  of  bouillon,  or  of  chicken  broth,  given 
hot,  to  within  a  few  hours  before  tlie  operation.  As  a  rule,  under  such 
circumstances,  alcoholic  drinks  of  whatever  variety  are  damaging  alike 
to  the  stomach  and  the  general  system,  and  should  be  avoided.  After 
the  ]3atient  has  been  placed  upon  the  table,  and  during  the  period  be- 
tween preliminary  unconsciousness  and  surgical  auEesthesia,  eight 
ounces  of  normal  salt  solution  should  be  injected  under  each  mammary 
gland.  This  practice  of  hypodermoclysis  is  adopted  by  Eeed,  as  a 
matter  of  routine,  in  all  cases  of  extreme  debility,  or  in  which  there  is 
reason  to  expect  considerable  hemorrhage  during  the  ensuing  opera- 
tion. A  small  dose  of  a  sixtieth  of  a  grain  of  strychnine  may  be  given 
hypodermically  at  this  time,  or  even  earlier.  Injections  of  large 
quantities  of  normal  salt  solution  into  the  rectum,  just  preceding  an 
operation,  while  theoretically  of  value,  generally  prove  worthless,  as 
they  are  usually  expelled  before  any  considerable  quantity  can  be 
absorbed.  Special  care  should  be  taken  in  debilitated  cases  to  keep  the 
extremities  warm,  to  protect  the  patient  from  currents  of  air,  and  to 
have  the  temperature  of  the  operating  room  as  high,  at  least,  as  the 
normal  bodily  temperature.  Another  prophylactic  measure  of  impor- 
tance is  Turck's  rubber  sack  filled  with  hot  water  and  introduced  into 
the  abdominal  cavity  during  an  operation  (Fig.  26). 

The  restorative  treatment  of  shock  consists  in  bringing  every  avail- 
able influence  to  bear  upon  the  re-establishment  of  the  inhibited  vital 
functions.     As  the  sympathetic  nervous  system  seems  to  be  the  pri- 


SHOCK 


75 


mary  factor  in  producing  those  phenomena  which,  in  the  aggregate, 
we  call  shock,  it  is  imperative  that  its  functions  be  re-established  as 
speedily  as  possible.  With  this  object  in  view,  heat  should  be  applied, 
both  over  and  within  the  stomach, 
carefully  wrapped,  or  any  other 
heated  object,  not  too  heavy, 
should  be  applied  over  the  region 


A  hot-water  bag,  a  hot  stove  lid, 


of  the  solar  plexus.  To  apply  heat 
within  the  stomach,  recourse  may 
be  had  to  Turek's  intragastric 
resuscitator  {Journal  of  the  Amer- 
ican Medical  Association,  January 
11,  1896),  which  is  constructed  on 
the  principle  of  a  recurrent  cathe- 
ter. This  is  introduced  into  the 
stomach,  which  is  then  subjected 
to  continuous  irrigation  with  hot 
water  at  a  temperature  of  130°  F. 
Heat  should  be  applied  to  the  ex- 
tremities. For  this  purpose  flan- 
nels wrung  out  of  hot  mustard 
water  are  of  value.  Friction  ap- 
plied to  the  extremities  may  be 
practised,  but  is  of  less  value  than 
moist  heat  associated  with  mild 
cutaneous  irritants.  Among  the 
remedies  valuable  in  these  cases 
are  to  be  mentioned  amyl  nitrite, 
given  by  inhalation,  and  nitro- 
glycerine, one  one-hundredth  of  a  grain,  given  hypodermically,  both  of 
which  are  almost  instantaneous  in  their  results.  They  are  equally 
evanescent  in  their  effects,  which  may  be  made  more  permanent  by  the 
coincident  administration  of  strychnine,  one-twentieth  of  a  grain;  but 
this  latter  remedy  should  not  be  repeated  in  less  than  an  hour,  as  its 
lethal  effects  may  be  induced  by  a  comparatively  small  dose  in  cases 
of  shock.  Crile  found  that  the  aqueous  extract  of  suprarenal  capsules 
of  sheep  caused  an  immediate  and  marked  rise  in  blood  pressure,  which 
effect  was  evanescent,  the  fall  being  as  rapid  as  the  rise.  In  view  of 
the  urgent  necessity  for  oxygen  in  these  cases,  Crile  esteems  artificial 
respiration  as  of  undoubted  importance,  and  has  recorded  observations 
of  its  salutary  effect  upon  the  vasomotor  and  heart  action,  and  hence 
upon  blood  pressure. 

Normal  salt  solution,  injected  in  large  quantities  under  the  skin,  or 
thrown  directly  into  the  veins,  is  a  remedy  of  extreme  value  in  the 
treatment  of  shock,  particularly  when  associated  with  hemorrhage. 
The  solution  is  prepared  by  dissolving  a  drachm  of  chloride  of  sodium 
in  a  pint  of  water.    In  the  ail)senco  of  the  chemically  pure  chloride  of 


Fig.  26. — "Another  prophylactic  measure 
is  Turek's  rubber  sack  filled  with  hot 
"water  and  introduced  within  the  abdom- 
inal cavity." — Keed  (page  74). 


76  A  TEXT-BOOK  OF   GYNECOLOGY 

sodium,  common  table  salt  may  be  employed,  and  while  it  is  always 
desirable  to  use  sterilized  water,  these  cases  are  generally  of  such  emer- 
gency and  occur  under  such  circumstances  that  it  is  not  practicable 
always  to  secure  even  water  sterilized  by  boiling.  Locke  has  suggested 
and  reported  favourably  upon  the  use  of  a  solution  prepared  according 
to  the  following  formula: 

I^   Calcium  chloride 3f  grains; 

Potassium  chloride 1^  grain; 

Sodium  chloride 2^  drachms. 

Sterilized,  distilled,  or  tap  water,  sufficient  to  make  one  quart. 

This  solution  is  used  either  for  hypodermoclysis,  for  enteroclysis,  or 
for  intravenous  infusion.  Schiicking,  of  Pyrmont,  acting  upon  the 
principle  that  paralysis  of  the  heart  after  great  loss  of  blood  is  always 
associated  with,  if  not  dependent  upon,  the  accumulation  of  COo  in  the 
tissues,  sought  some  combination  which  would  neutralize  this  gas. 
The  task  of  eliminating  the  CO,  under  normal  circumstances  is  al- 
lotted to  paraglobulin,  the  alkaline  compound  proteid  of  the  blood,  and 
Schiicking  assumed  that  saccharate  of  sodium  might  take  its  place,  inas- 
much as  this  compound  is  split  up  by  COo  into  sugar  and  sodium  car- 
bonate, thus  fixing  the  COo.  He  therefore  employs  the  saccharate  of 
sodium  in  the  form  of  a  0.03-per-cent  subcutaneous  injection  with  0.6 
per  cent  of  salt,  and  reports  success  with  its  use  (250  grammes)  after  an 
alkaline  salt  solution  had  proved  useless.  The  addition  of  albumen  or 
serum  or  other  organic  elements  to  the  fluid  is  both  unnecessary  and 
dangerous.  Transfusion  of  Hood  from  one  person  to  another  has  be- 
come almost  obsolete  since  the  practical  value  of  the  normal  salt 
solution  has  become  understood. 

Subcutaneous  infusion  of  normal  salt  solution  (hypodermoclysis) 
may  be  practised  by  inserting  beneath  the  mammary  gland,  or  deep  into 
any  area  of  loose  cellular  tissue,  the  sterilized  needle  of  an  aspirator, 
attached  either  to  an  ordinary  Davidson's  syringe  or  to  a  fountain  syr- 
inge. Elaborate  special  apparatus  for  this  purpose  is  totally  unneces- 
sary in  the  hands  of  an  operator  who  is  familiar  with  the  technique  of 
asepsis.  From  six  to  eight  ounces  of  the  solution  should  be  gently  and 
gradually  injected.  The  tumour  which  rapidly  develops  by  the  accu- 
mulation of  the  fluid,  should  be  subjected  to  gentle  friction, which  seems 
to  facilitate  the  diffusion  of  the  fluid.  The  infusion  can  be  made 
under  both  breasts  at  the  same  time,  or,  for  that  matter,  even  into  other 
areas.  Care  should  be  taken  to  avoid  throwing  a  considerable  volume 
of  fluid  immediately  beneath  the  integument,  or  where  the  skin  is  not 
provided  with  an  ample  cushion  of  underlying  cellular  tissue,  as  the 
pressure  that  may  otherwise  be  induced  may  cause  superflcial  destruc- 
tion of  the  skin. 

Subcutaneous  infusion  is  so  readily  practised  and  is  so  destitute 
of  danger  that  it  should  be  accepted  as  the  operation  of  choice,  as 
against  intravenous  injection,  in  all  cases  in  which  the  shock  is  not 


SHOCK  77 

profound,  or  the  hemorrhage  has  not  been  excessive,  or  in  which  delay 
of  from  fifteen  to  twenty  minutes  may  be  indulged  before  the  fluid 
finds  its  way  into  the  circulation. 

Intravenous  infusion  of  normal  salt  solution  is  practised  by  open- 
ing one  of  the  superficial  veins  of  the  forearm.  This  is  done  by  com- 
pressing the  vein  until  it  becomes  distended  with  blood;  a  small  inci- 
sion is  then  made  through  the  integument  until  the  vein  is  reached. 
This  is  then  picked  up  by  means  of  a  grooved  director,  and  two  ligatures, 
half  an  inch  apart,  are  placed  in  position.  The  distal  ligature  is  then 
tied;  a  small  opening  is  made  into  the  vein  between  the  two  ligatures; 
through  this  opening  a  small  blunt-pointed  trocar  is  introduced  into  the 
lumen  of  the  vein  to  a  point  above  the  location  of  the  proximal  liga- 
ture, which  is  now  tightened  around  both  the  trocar  and  the  vein. 
Care  should  be  taken  before  inserting  the  trocar  to  see  that  it  is  filled 
with  water  from  the  syringe  or  reservoir  with  which  it  is  connected. 
After  the  trocar  has  been  inserted  into  the  vein  and  the  ligature  has 
been  tightened  around  it,  the  fluid  is  permitted  to  flow  into  the  vein. 
This  fluid  should  not  be  permitted  to  fall  to  a  temperature  below  100° 
F.,  and  it  should  be  used  from  a  graduate  or  some  other  reservoir  by 
which  its  quantity  may  be  determined.  Not  less  than  eight  ounces 
should  be  inserted  at  one  time  in  the  case  of  shock,  while  a  quantity 
equal  to  or  slightly  in  excess  of  the  amount  of  blood  lost,  should  be 
injected  in  case  of  hemorrhage,  but  not  until  the  bleeding  vessel  has 
been  tied.    (See  Treatment  of  Hemorrhage.) 

Rectal  Infusion  {Enterodysis). — Cases  may  occur  in  which  it  is  not 
convenient  at  the  moment  to  practise  either  intravenous  or  subcutaneous 
infusion  because  of  the  absence  of  the  necessary  apparatus,  while  there 
are  other  cases  in  which  the  loss  of  blood  has  been  so  great,  and  the 
shock  is  so  profound,  that  it  is  desirable  to  employ  not  only  the  fore- 
going expedients,  but  any  auxiliary  to  them.  Under  these  circum- 
stances a  considerable  quantity  of  the  normal  salt  solution,  heated  to 
110°  or  115°  F.,  may  be  thrown  into  the  rectum.  More  than  six  or 
eight  ounces  should  not  be  employed,  as  overdistention  of  the  bowel 
will  defeat  the  purpose  of  the  injection  by  causing  a  rejection  of  the 
fluid.  If,  however,  it  is  desired  to  use  a  greater  quantity,  it  should  be 
given  as  a  high  enema.  This  is  done  by  placing  the  patient  upon  the 
left  side,  with  the  legs  flexed  and  the  hips  elevated,  and  permitting 
from  a  quart  to  a  half  gallon  of  the  fluid  gradually  to  enter  the  ali- 
mentaiy  canal.  This  is  not  only  an  effective  way  of  applying  heat,  but, 
by  bringing  the  fluid  in  contact  with  the  powerfully  absorbent  surfaces 
of  the  colon,  the  procedure  becomes  an  effective  way  of  reaching  the 
circulation. 


CHAPTEE    X 

HEMORRHAGE   AND   HEMOSTASIS 

Hemorrhage,  obvious  and  concealed — Symptoms — Diagnosis — Treatment:  Hemo- 
stasis,  styptics,  heat,  pressure,  angeiotripsy,  eleetro-hemostasis,  ligatures. 

Hemoeehage  may  be  studied  under  the  head  of  (a)  obvious,  and  (b) 
concealed.  Obvious  hemorrhage  may  be,  in  origin,  botli  internal,  as 
in  metrorrhagia,  and  external,  as  in  operations.  Concealed  hemor- 
rhage, on  the  other  hand,  is  always  internal,  as,  for  instance,  in  rupture 
of  a  tubal  pregnancy  or  a  slipped  pedicle  in  ovariotomy. 

Symptoms  of  Hemorrhage. — When  hemorrhage  is  obvious — i.  e., 
when  there  is  an  external  flow,  Avhatever  may  be  the  origin  of  the  blood 
— the  mere  presence  of  the  latter  is  all  that  is  necessary  for  diagnosis, 
except,  perhaps,  in  the  instance  of  sanguineous  discharges  from  the 
uterus.  Under  these  circumstances  it  is  sometimes  important  to  dis- 
criminate between  the  menstrual  flow  and  hemorrhage  from  other 
causes  (see  Menstruation).  The  question  of  internal  hemorrhage,  how- 
ever, is  one  which  demands  solution  in  the  light  of  symptoms  other 
than  an  obvious  discharge  of  blood.  Hemorrhage  rarely,  if  ever,  occurs 
without  occasioning  discomfort,  amounting  in  cases  to  acute  pain  in 
the  locality  in  which  it  occurs.  Pain  is,  therefore,  to  be  regarded  as 
the  usual  initial  symptom,  particularly  in  all  cases  of  vascular  rupture. 
There  is  generally  so  much  pain  present,  following  an  intrapelvic  oper- 
ation, that  the  slipping  of  the  ]Dedicle,  for  example,  would  give  rise  to  no 
conscious  sensation,  unless  by  the  relief  of  the  pressure  there  occurred 
some  amelioration  of  the  pre-existing  discomfort.  The  pulse  is  accel- 
erated from  the  first,  but  the  acceleration  increases  coincidently  with 
the  duration  of  the  hemorrhage.  AVith  the  increased  frequency  of  the 
heart  beat  there  is  a  progressive  diminution  in  the  volume  and  tension 
of  the  pulse.  The  temperature  speedily  becomes  subnormal.  The  res- 
piration, at  first  but  slightly  disturbed,  speedily  becomes  frequent  and 
irregular,  the  patient  sighing  in  her  efforts  to  secure  enough  oxygen 
to  neutralize  the  rapidly  accumulating  carbonic  dioxide  in  her  system. 
Irregular  muscular  activity  is  noted;  the  lips  become  livid  and  the 
finger  nails  blue;  there  is  general  pallor  of  the  face  and  of  the  mucous 
surfaces;  the  skin  becomes  bathed  in  perspiration;  strange  sounds  are 
heard  and  muttering  delirium  ensues,  in  the  midst  of  which  the  pa- 
tient's eyes  become  staring;  the  alse  of  the  nose  become  dilated;    the 


HEMORRHAGE  AND   HEMOSTASIS  79 

features  become  pinched,  until  collai^se,  unconsciousness,  and  death, 
close  the  scene. 

Diagnosis  of  Hemorrhage. — (See  Diagnosis  of  Shock.) 

Treatment  of  Hemorrhage. — The  treatment  of  hemorrhage,  classi- 
fied inversely  to  its  importance,  is  both  (a)  constitutional,  and  {b)  local. 
Constitutional  measures  must  be  addressed  to  the  conservation  of  the 
remaining  circulatory  medium,  to  the  relief  of  the  practically  always 
concomitant  symptoms  of  shock,  and  finally  to  the  speedy  restoration 
of  the  volume  of  the  blood.  Practically  all  these  measures  are  con- 
sidered in  detail  under  the  head  of  Treatment  of  Shock,  which  should 
be  read  in  this  connection. 

The  local  treatment  should  be  based  upon  the  general  surgical 
axiom  to  "  cut  down  and  tie  the  bleeding  vessel "  in  the  presence  of 
concealed  hemorrhage  of  a  degree  sufficient  to  cause  constitutional 
symptoms.  The  more  profound  the  shock,  the  more  imperative  is  this 
decree,  the  operation  of  which  may  in  certain  instances  result  in  surgi- 
cal intervention  for  the  relief  of  hemorrhage  capable  of  spontaneous 
arrest.  This  is  exemplified  in  hemorrhages  into  the  broad  ligament, 
which,  through  the  joint  influence  of  the  peritoneal  investment  and 
the  formation  of  hemorrhagic  infarcts,  may  come  to  a  spontaneous  ter- 
mination, resulting  ultimately  in  the  absorption  of  the  clot.  These 
cases,  which  will  be  considered  more  in  detail  in  connection  with 
ectopic  pregnancy,  and  which  serve  as  the  most  favourable  examples  of 
concealed  hemorrhage,  are  more  safely  treated,  as  a  rule,  by  operation. 
In  superficial  hemorrhage,  where  the  bleeding  vessel  is  accessible,  it 
should  be  brought  under  immediate  control  by  some  of  the  various 
expedients  to  be  considered  under  the  head  of  hemostasis. 

Hemostasis. — Control  of  hemorrhage  was  one  of  the  most  perplex- 
ing problems  in  the  early  development  of  gynecologic  surgery.  The 
earlier  mortality  tables  exhibit  what  to-day  would  be  looked  upon  as 
an  alarmingly  high  percentage  of  deaths  from  hemorrhage.  The  pres- 
ent resources,  however,  are  so  adequate,  that  a  death  from  hemorrhage 
under  ordinary  circumstances  places  the  surgeon  upon  the  defensive. 
Hemostatic  measures  may  be  considered  under  the  heads  of  (a)  styptics, 
(b)  heat,  (c)  pressure,  (d)  electro-hemostasis,  (e)  ligatures. 

Styptics. — Styptics  consist  of  those  remedies  which  exercise  an  as- 
tringent effect  upon  the  tissues  to  which  they  are  applied.  Practically 
all  the  mineral  astringents  possess  more  or  less  styptic  properties. 
Sulphate  of  iron,  sulphate  of  zinc,  acetate  of  lead,  and  sulphate  of 
copper,  are  examples  in  point.  All  vegetable  preparations  possessing 
styptic  properties  depend  for  their  activity  upon  the  presence  of  tannin. 
Extract  of  the  suprarenal  capsule  applied  to  oozing  surfaces  exercises 
an  instantaneous  influence  over  capillary  hemorrhage.  Among  the 
most  valuable  of  styptics,  and  the  more  valuable  because  it  is  prac- 
tically always  at  hand,  is  dilute  acetic  acid  in  the  form  of  commercial 
vinegar,  such  as  is  found  in  almost  every  household.  This  may  be 
apl)licd  fjLire,  or-  in  tlic  foi-iti  of  a  douche,  one  part  of  vinegar  to  four 


80  A  TEXT-BOOK  OF   GYNECOLOGY 

parts  of  water,  or  gauze  may  be  saturated  with  it  and  packed  into  a 
bleeding  cavity.  Any  vessel,  the  hemorrhage  from  which  occurs  in  the 
form  of  an  intermittent  jet,  is  too  large  to  be  intrusted  safely  to  a 
styptic. 

Heat. — Heat  is  a  hemostatic  of  broad  application  in  abdominal  and 
pelvic  surgery.  Its  use  is  based  upon  the  fact  that  it  has  the  effect 
of  constricting  the  blood  vessels  subjected  to  its  influence,  or  in  higher 
degrees  of  temperature  it  may  desiccate  and  even  char  the  tissues. 
When  heat  is  so  great  as  to  immediately  destroy  the  continuity  of 
structure,  it  does  not  control  hemorrhage  from  vessels  of  larger  calibre. 
In  metrorrhagia,  or  in  intrauterine  oozing  following  operations  within 
the  cavity  of  the  uterus,  it  is  a  valuable  remedy  when  applied  in  the 
form  of  an  intrauterine  douche.  To  be  effective,  the  temperature  should 
be  not  less  than  115°  F.,  and  the  application  should  be  continued  for 
not  less  than  fifteen  minutes.  Hot  sponge  packing  is  an  exceedingly 
valuable  expedient  in  controlling  diffuse  capillary  oozing  in  intrapelvic 
and  other  operations.  Sponges,  or,  for  that  matter,  the  gauze  napkins 
noAv  almost  universally  employed,  should  be  wrung  out  of  water  at  a 
temperature  of  not  less  than  120°  F.,  and  immediately  placed  in  con- 
tact with  the  oozing  surface.  They  should  be  left  there  for  several 
minutes — long  enough  to  secure  the  secondary  effect  of  heat  upon  the 
capillaries.  For  this  purpose  sponges  are  better  than  the  gauze,  be- 
cause they  possess  elastic  properties,  which  increase  the  pressure,  also 
a  valuable  element  in  the  control  of  bleeding. 

The  actual  cautery  is  one  form  of  the  application  of  heat  for  the 
control  of  hemorrhage.  Irons  variously  shaped  and  fitted  into  handles 
are  heated  and  applied  to  the  bleeding  surface.  Keith  caught  the 
pedicle  of  a  fibroid  tumour  in  a  nonconducting  clamp,  and  then  by 
means  of  hot  irons  heated  to  a  red  glow,  and  persistently  applied  for 
several  minutes,  reduced  the  stump  to  a  state  of  complete  desiccation, 
rendering  the  hemostasis  absolute.  Paquelin's  thermocautery  is  merely 
a  more  convenient  form  of  the  old  actual  cautery.  It  consists  of  vari- 
ous shaped  platinum  tips,  hollow,  containing  coils  of  platinum  wire, 
and  communicating  with  a  reservoir  containing  benzole.  Over  this 
chamber  of  benzole  a  current  of  air  is  passed,  creating  a  combustible 
vapour,  which  is  burned  in  the  hollow  platinum  point  of  the  instru- 
ment. By  regulating  the  pressure  upon  the  bulb  the  heat  can  be  cor- 
respondingly regulated.  The  instrument  is  vastly  more  convenient 
than  the  old  irons,  which  have  become  practically  obsolete. 

Pressure. — Actual  pressure  may  be  exerted  by  the  fingers  or  thumbs 
placed  upon  a  bleeding  vessel.  Elastic  pressure  is  practised  by  encir- 
cling a  bleeding  part  with  an  elastic  ligature,  stretched  to  a  degree 
of  considerable  tension,  and  secured  either  by  a  knot  or  catch  forceps. 
These  should  be  recognised  merely  as  temporary  expedients,  as  it  is 
manifestly  impossible  to  sustain  the  former  for  long,  while  the  latter 
soon  induces  tissue  necrosis  from  pressure.  Forcipressure  is  practised  by 
seizing  the  bleeding  vessel  with  a  forceps.     This  principle  has  been 


HEMORRHAGE   AND   HEMOSTASIS  81 

recognised  in  surgery  from  antiquity,  but  it  was  left  for  Koeberle  and 
Pean  to  devise  the  useful  instruments  now  known,  respectively,  by 
their  names  (see  Armamentarium).  It  may  be  said  without  contradic- 
tion that  the  introduction  of  this  instrument,  for  they  are  practically 
the  same,  has  added  vastly  to  the  usefulness  of  surgery.  It  has  been 
variously  modified  into  long  and  short,  thick  and  thin,  straight  and 
•  curved,  light  and  heavy,  but  the  principle  involved  is  the  same  in  all 
of  them.  The  forceps  consists,  essentially,  of  two  scissorlike  blades,  the 
•distal  extremities  of  which  are  arranged  into  serrated,  approximating 
jaws,  while  the  proximal  ends  are  arranged  with  the  usual  scissor- 
handle  rings  and  an  intervening  catch  to  admit  of  regulated  pressure 
and  fixation.  The  hemostatic  forceps  is  usually  applied  for  the  imme- 
diate and  temporary  arrest  of  hemorrhage.  In  very  small  vessels,  as, 
for  instance,  in  the  abdominal  incision,  the  pressure  thus  exercised  is 
sufficient  permanently  to  control  the  bleeding;  while  in  larger  vessels  a 
ligature  should  be  applied  before  the  forceps  is  removed.  For  this 
3)urpose  a  forceps  of  relatively  thick  jaws  and  tapering  to  a  sharp  point 
is  desirable,  as  it  permits  the  ligatiire  to  slide  readily  upon  the  vessel. 
Jn  certain  localities  it  is  not  practicable  to  apply  a  ligature  to  control 
the  hemorrhage,  under  which  circumstances  the  forceps  is  left  in  situ 
ior  a  period  of  not  less  than  twenty-four  hours.  It  occasionally  hap- 
pens that  the  tissues  in  the  field  of  operation  are  so  friable  that  they 
will  not  resist  the  pressure  of  a  ligature,  when  continuous  pressure  by 
"the  forceps  becomes  essential. 

Angeiotripsy. — The  angeiotribe,  or  pressure  forceps,  is  an  instru- 
rment  designed  to  do  away  with  the  use  of  ligatures  or  retention  forceps 
in  removal  of  the  uterus,  and  in  extirpation  of  the  tubes,  ovaries,  and 
tumours  having  suitable  pedicles.  It  is  founded  upon  the  surgical 
principle  of  preventing  hemorrhage  by  the  formation  and  retention  of 
blood  clot.  It  may  be  used  in  both  vaginal  and  abdominal  section,  but 
not  upon  omental  and  like  fragile  tissue.  It  is  presented  in  many 
forms,  all  having  the  same  mechanical  purpose,  but  differing  in  the 
application  of  the  force  principle.  The  pressure  is  obtained  by  means 
of  the  accurate  adjustment  of  blades  to  which  a  pressure  of  three 
thousand  pounds  is  imparted  by  the  mechanism  of  the  handles.  TufFier 
•employs  screw  pressure;  Doyen  and  Thumin  the  lever;  and  there  are 
■other  modifications  of  both  these  principles  in  use. 

The  cut  (Fig.  27)  shows  the  ISTewman  angeiotribe  furnished  with 
both  lever  and  screw  as  adjustable  attachments,  and  designed  for  both 
vaginal  and  abdominal  work.  (See  chapter  on  Panhysterectomy.)  The 
method  of  its  employment  is  illustrated  in  vaginal  hysterectomy.  The 
operator  proceeds  as  usual  until  the  uterus  is  freed  from  its  anterior 
and  posterior  attachments,  including  all  adhesions,  and  remains  sus- 
pended only  by  the  broad  and  round  ligaments.  The  left  broad  liga- 
ment is  now  hooked  flown  by  means  of  the  left  index  and  middle  fingers 
■or  a  large  blunt  hook  of  the  Eastman  variety,  and  included  in  the  bite 
of  the  angeiotribe.  An  assistant  steadies  the  instrument  while  the 
7 


82 


A   TEXT-BOOK   OF   GYNECOLOGY 


screw  is  adjusted  to  tlie  requisite  pressure  and  allowed  to  remain  for  one 
or  two  minutes.  While  the  instrument  is  in  situ  the  ligament  is  divided 
with  scissors  between  clamp  and  uterus,  leaving  a  margin  of  say  a  half 

centimetre  of  tissue,  constituting 
a  small,  neat  stump,  of  ribbonlike 
thinness.  This  dissection  re- 
leases the  uterus  from  its  attach- 
ments upon  the  left  side,  and  it 
is  a  simple  matter  to  draAv  it 
down  outside  the  vulva,  so  as  to 
expose  the  right  ligament.  The 
clamp  is  now  best  applied  from, 
above  downward,  and  the  liga- 
ment is  cut  as  on  the  opposite 
side. 

When  the  instrument  is  re- 
leased for  the  last  time  and  re- 
moved, careful  toilet  and  inspec- 
tion of  the  entire  field  of  opera- 
tion are  made,  and  the  sterilized 
gauze  packing  used  in  the  cus- 
tomary manner,  or  a  running 
catgut  suture,  including  peri- 
toneal and  vaginal  surfaces, 
closes  the  vaginal  vault,  catch- 
ing up  the  contracted  stumps  in 
each  angle  of  the  wound.  The 
external  dressings  are  applied  as 
usual,  but  the  after-treatment  is 
greatly  simplified,  as  there  are  no 
retention  forceps  to  be  watched 
and  removed,  and  no  ligatures  to 
come  away. 

There  is  little  or  no  pain,  and 
the  comfortable  condition  of  the 
patient  after  recovery  from  anesthesia  is  in  marked  contrast  to  suffer- 
ings of  other  patients  under  the  retention  clamp  method. 

Wlien  it  is  found  difficult  to  secure  the  entire  broad  ligament  at  one 
application  the  angeiotribe  may  be  applied  twice  upon  each  side,  com- 
pressing first  the  lower  half  of  the  left  ligament,  including  the  uterine 
artery,  then  the  same  area  upon  the  right  side.  With  the  lower  half  of 
the  broad  ligament  cut  free  of  the  uterus,  the  upper  half  can  usually 
be  easily  drawn  down  by  the  fingers  or  broad  ligament  hook,  and  the 
clamp  applied  upon  its  remaining  portion  containing  the  ovarian 
artery. 

Another  method,  and  one  which  Newman  frequently  uses,  consists 
in  applying  temporarily  to  the  base  of  the  ligament  the  ordinary  clamp 


Fig.  27.^"  The  Newman  angeiotribe  furnished 

with  lever  and  screw." — Newman  (page  81). 


HEMORRHAGE   AND   HEMOSTASIS  83 

or  ligature,  cutting  this  portion,  inverting  the  uterus  forward  out  of 
the  anterior  peritoneal  opening,  and  applying  the  angeiotribe  on  each 
side  from  above  downward  the  entire  width  of  the  broad  ligament,  in- 
cluding the  stump  of  the  previously  clamped  or  ligated  base. 

The  dry  pack  is  another  means  of  applying  pressure,  especially 
within  the  peritoneal  cavity,  the  cavity  of  the  uterus,  and  the  vagina. 
Within  the  peritoneal  cavity,  the  method  of  Mikulicz,  who  introduced 
the  practice,  is  as  follows:  The  cavity  is  lined,  preferably  with  a  pocket 
formed  of  iodoform  gauze.  Into  this  pocket  a  rope  of  iodoform  gauze 
is  stuffed  until  the  entire  cavity  is  filled.  It  should  be  packed  with 
sufficient  firmness  to  insure  pressure  upon  the  proximal  bleeding  sur- 
face. This  practice  has  been  modified  very  generally  by  simply  pack- 
ing the  bleeding  cavity  with  a  rope  of  sterilized  gauze,  without  taking 
the  precaution  to  line  the  cavity  with  a  gauze  pouch.  Packing  thus 
introduced  should  not  be  withdrawn  under  less  than  twenty-four  hours; 
after  this  time,  if  the  vessels  are  not  very  large,  hemostasis  is  reason- 
ably certain. 

Uledro-hemostasis. — Electro-hemostasis  is  in  reality  but  another 
form  of  controlling  hemorrhage  by  heat.  In  this  instance  the  heat  is 
generated  by  the  electric  current  and  is  brought  in  contact  with  the 
tissues  by  means  of  the  electric  loop,  the  electric  knife,  the  electric 
forceps,  or  by  means  of  a  platinum  cautery  tip.  The  same  propor- 
tions should  be  observed  in  the  application  of  electricity  for  hemostatic 
purposes  that  are  prescribed  for  the  use  of  heat  in  any  other  form 
applied  to  the  control  of  hemorrhage.  The  most  essential  of  these 
precautions  are,  first,  to  avoid  the  use  of  too  high  a  degree  of  heat,  and 
secondly,  to  protect  adjacent  structures  from  its  action. 

John  Byrne,  of  Brookl3ai,  was  the  first  to  popularize  the  galvano- 
cautery  in  America,  and  to  him  is  due  the  credit  of  demonstrating  its 
hemostatic  possibilities  in  high  amputation  of  the  cervix  for  cancer. 
It  can  not  be  said,  however,  that  this  operation  is  the  most  crucial  test 
to  which  a  hemostatic  measure  can  be  subjected,  for  the  reason  that 
high  amputation  of  the  cervix  can  be  j)ractised  as  an  almost  bloodless 
operation,  without  the  use  of  any  hemostatic  whatever.  As  used  by 
Byrne,  the  instrument  consists  of  a  loop  of  platinum  wire,  passed 
through  a  noose  carrier  and  both  ends  of  it  attached  to  a  key,  not  unlike 
that  of  a  violin,  whereby  the  size  and  tension  of  the  loop  can  be  accu- 
rately regulated.  Either  end  of  the  wire  is  brought  into  contact  with 
the  opposite  poles  of  the  battery,  which  may  be  either  a  storage  battery 
or  a  primary  battery,  or  the  current  may  be  taken  from  an  electric- 
light  circuit  and  utilized  through  the  medium  of  a  transformer.  Fur- 
ther details  of  the  use  of  the  electric  loop  will  be  mentioned  in  connec- 
tion with  vaginal  hysterectomy.  The  electric  knife  consists  of  a  smaller 
loop  of  platinum  wire,  flattened  and  fixed  in  a  nonconducting  handle, 
through  which  it  passes,  and  is  attached  to  the  battery.  By  means  of 
the  regulator  this  blade  can  be  brought  to  any  degree  of  temperature 
desircfl.    A\'licn,  iiowever,  it  is  utilized  to  pass  through  tissues,  it  must 


84 


A  TEXT-BOOK  OF   GYNECOLOGY 


be  heated  to  so  high  a  degree  that  its  hemostatic  properties  are  rela- 
tively diminished.  When  using  either  the  electric  loop  or  the  electric 
knife,  the  handles,  of  whatever  material  constructed,  should  be  wrapped 
with  moist,  sterilized  flannel,  to  protect  the  vagina  from  the  action  of 
the  heat. 

Hemostasis  by  the  use  of  the  electric  forceps  is  one  of  the  most  valu- 
able of  our  recent  additions  to  surgery,  the  credit  for  whose  invention 

belongs  to  the  late  Dr.  Skene,  of 
Brooklyn.  It  is  an  adaptation  of 
heat  and  pressure,  in  combination, 
to  the  control  of  hemorrhage.  In 
its  simplest  form  the  apparatus  con- 
sists of  the  electric  forceps  proper, 
conducting  cables,  and  a  storage 
battery  (Fig.  28).  Instead  of  the 
latter,  the  current  may  be  taken 
from  an  electric-light  plug  and 
passed  through  a  transformer, 
with  which  the  forceps,  in  turn,  is 
connected.  If  the  electric-light 
current  is  continuous,  a  rotary  con- 
verter will  be  required  to  convert  it 
into  an  alternating  current  suitable 
for  operating  the  transformer.  The 
forceps  may  be  of  various  forms  and 
sizes.  "  One  jaw  of  the  forceps  is 
hollow  and  is  heated  by  having  a 
resistance  wire  located  at  the  bot- 
tom of  the  chamber  close  to  the 
face  of  the  jaw,  from  which  it  is 
insulated  by  a  thin  layer  of  fire- 
proof material.  The  chamber  above 
the  wire  is  filled  with  insulating 
material,  which  is  also  a  noncon- 
ductor of  heat,  such  as  asbestos, 
and  is  so  closed  by  a  sheet  metal 
cover  as  to  be  watertight.  One  end 
of  the  resistance  wire  is  connected 
to  the  jaw  and  the  other  to  an  in- 
sulated copper  wire  placed  in  a 
metal  tube,  which  extends  from  the 
chamber  along  the  shaft  of  the  for- 
ceps handle  to  a  metal  block,  which 
is  attached  near  the  ring  end  of  the  forceps  handle.  A  copper  wire  is 
here  connected  to  an  insulated  terminal  mounted  in  the  block.  A 
similar  terminal  is  attached  directly  to  the  block  and  is  uninsulated. 
By  this  means  of  construction  the  electrical  wires  are  incased  in  metal. 


Fig.  28.— "The  apparatus  consists  of  the 
electric  forceps  proper,  conducting  ca- 
bles, and  a  storage  battery." — Eeed. 


HEMORRHAGE   AND   HEMOSTASIS  85 

SO  that  the  forceps  can  be  sterilized  and  handled  without  injury,  the 
same  as  any  ordinary  instrument.  Starting  at  the  insulated  terminal, 
the  path  of  the  current  is  through  the  copper  wire  and  the  resistance 
wire  to  the  tip  of  the  jaw,  thence  through  the  blade  of  the  forceps 
to  the  uninsulated  terminal.  The  copper  wire  and  the  blade  of  the 
forceps  form  a  path  of  good  electrical  conductivity,  and  are  conse- 
quently but  slightly  heated  by  the  passage  of  the  current  used.  On 
the  other  hand,  the  wire  in  the  chamber  is  a  poor  conductor  and  is 
heated  to  a  greater  or  less  degree,  according  to  its  resistance  and 
the  strength  of  the  current." 

Before  applying  the  electric  forceps  it  is  sterilized,  just  as  is 
any  other  instrument;  but  care  should  be  taken  after  its  removal 
from  the  sterilizer  to  avoid  placing  it  immediately  into  cold  water, 
as  the  contraction  thereby  induced  may  result  in  destroying  the 
air-tight  qu.ality  of  the  jaw  containing  the  insulated  terminals.  The 
rubber-covered  end  of  the  electrical  cable  is  best  sterilized  in  boiling 
water,  and  should  then  be  wrapped  in  a  sterilized  towel,  or  immersed 
in  a  five-per-cent  carbolic  solution.  A  little  sterilized  vaseline  should 
be  placed  on  the  approximating  surfaces  of  the  jaws  of  the  instrument 
to  prevent  the  tissues  from  adhering  to  them. 

The  method  of  using  the  electric  forceps  consists  in  firmly  com- 
pressing a  portion  of  the  bleeding  tissue,  or  preferably  the  end  of  the 
bleeding  vessel,  between  the  jaws  of  the  instrument,  the  object  being  to 
expel  as  much  of  the  moisture  as  possible,  before  the  electric  current 
is  turned  on,  an  expedient  which  greatly  facilitates  the  subsequent 
process  of  desiccation.  The  forceps  is  then  subjected  to  the  current, 
and  by  that  means  heated  to  a  temperature  of  from  180°  to  190°  F., 
just  enough  to  desiccate  but  not  to  char  the  tissues. 

All  tissues  to  be  treated  should  be  firmly  compressed  between  the 
jaws  of  the  instrument  applied  cold  and  subsequently  heated.  If  this 
precaution  is  not  observed,  it  Avill  be  necessary  to  reapply  the  instru- 
ment, and  thus  consmne  additional  time.  Skene  advises  that  before 
the  electric  current  is  turned  on  a  piece  of  gauze  or  a  shield  should 
be  applied,  where  needed,  between  the  forceps  and  the  adjacent  tissues, 
to  protect  them  from  injury  by  contact  with  the  hot  instrument.  The 
forceps  should  be  left  on  from  thirty  seconds  to  two  minutes,  accord- 
ing to  the  thickness  of  the  tissues  or  the  size  of  its  contained  vessels. 
Before  it  is  removed  the  tissues  projecting  beyond  its  jaws  are  cut  off, 
and  the  pedicle  beneath  is  seized  with  a  shield  or  compression  forceps 
to  hold  the  stump  in  position  for  inspection.  The  forceps  is  then  grad- 
ually opened  and  the  desiccated  stump  is  permitted  to  slide  out  from 
between  the  jaws  in  the  direction  of  the  teeth.  Skene  insists  upon 
this  precaution  as  one  of  importance.  The  absence  of  bleeding  upon 
the  removal  of  the  forceps  indicates  that  the  desiccation  has  been  suffi- 
ciently effective,  and  Skene  assures  us  the  stump  can  be  left  without 
fear  of  secondary  hernorrbagc.  IP,  however,  bleeding  should  occur  im- 
mdifitely  upon  ilio  removal  of  tlie  forceps,  the  latter  should  be  reap- 


86  A  TEXT-BOOK  OF  GYNECOLOGY 

plied  at  once,  and  the  heating  should  be  repeated  with  about  ten  per 
cent  more  current,  or  for  a  longer  time.  In  this  way  the  tissues  will 
become  thoroughly  desiccated,  but  not  charred,  and  the  blood  vessels 
so  thoroughly  occluded  that  they  can  not  be  opened  up  again,  either  by 
blood  pressure  or  the  most  critical  dissection. 

Ligatures. — It  is  a  suggestive  fact  that  practically  all  accepted  liga- 
ture materials  are  of  animal  origin.  This  remark  is  intended  to  apply 
to  silk,  which,  being  the  product  of  the  silkworm,  is  quite  as  much  an 
animal  as  it  is  a  vegetable  product.  Silk  has  been  the  material  of  pref- 
erence for  ligature  purposes  for  many  years.  It  has  the  advantages  of 
being  strong,  very  flexible,  capable  of  being  tied  in  a  firm  knot,  and 
within  the  peritoneal  cavity  it  is  capable  of  absorption  by  the  tissues. 
On  the  other  hand,  there  is  much  difficulty  in  securing  a  p^ire  article, 
and  its  adulteration  with  either  cotton  or  flax  renders  it  incapable  of 
absorption  when  used  in  intrapelvic  work.  It  is  as  difficult  of  steriliza- 
tion as  is  catgut  or  any  other  of  the  distinctly  recognised  animal  liga- 
ture materials.  It  will  not  become  absorbed  when  used  as  a  buried 
suture  in  the  parietal  tissues,  and  in  the  presence  of  infection  it  be- 
comes the  nidus  for  the  development  of  secondary  abscesses,  sinuses,  etc. 
If  silk  is  used,  care  should  be  taken  to  ascertain  that  it  is  pure.  This 
can  be  done  by  dropping  a  piece  of  the  thread  into  liquor  potassse;  if  in 
the  course  of  twelve  hours  it  thoroughly  dissolves,  it  may  be  accepted 
as  pure;  if  shreds  remain,  the  fact  may  be  accepted  as  evidence  that  it 
is  adulterated  with  either  cotton  or  linen,  and  should  be  discarded. 
In  its  preparation  for  use  it  should  be  sterilized  by  boiling  at  a  high 
degree  from  fifteen  to  twenty  minutes,  or  subjected  to  steam  pres- 
sure of  not  less  than  forty-five  pounds  to  the  square  inch  during  a  sim- 
ilar period,  after  Avhich,  for  further  jjrotection,  it  should  be  kept  in  a 
solution  of  absolute  alcohol  containing  not  less  than  two  per  cent  of 
carbolic  acid.  It  can  be  prepared  in  difi^erent  sizes  and  should  be  kept 
in  hermetically  sealed  jars,  through  an  elastic  covering  of  which  it  can 
be  drawn  as  needed.  It  should  be  remembered  that  silk  kept  in  a  state 
of  moisture  for  any  considerable  length  of  time  will  disintegrate  to  a 
degree  that  renders  it  unfit  for  use.  Catgut  is  a  ligature  material 
of  great  popularity,  for  the  proper  preparation  of  which  see  Antisepsis. 


CHAPTER    XI 

ANiESTHETICS  AND  ANESTHESIA   IN   GYNECOLOGY 

Definitions — Anaesthetic  agents — Relative  safety  of  ether  and  cliloroform — Race 
and  temperament  in  the  selection  of  an  ana3sthetic — Indications  and  contra- 
indications for  the  use  of  ether  and  chloroform — Ether  in  relation  to  bodily 
temperature — Choice  of  anassthetic  for  children — Bromide  of  ethyl,  indications 
and  contraindications — Administration  of  ether — Of  mixed  vapours — Of  chlo- 
roform— Of  bromide  of  ethyl — Management  of  respiratory  and  other  accidents 
— Anaesthetic  mixtures — Central  anassthesia  by  cocaine — General  anaesthesia 
by  alcohol — By  hypnosis — Local  anaasthesia. 

Anesthesia  is  a  term  suggested  by  Oliver  Wendell  Holmes  as  a 
proper  one  for  the  condition  produced  by  the  inhalation  of  sulphuric 
ether,  and  it  has  been  universally  adopted  in  all  countries  and  languages 
and  extended  in  its  application,  very  properly,  to  all  forms  of  loss  of 
pain  sense,  whatever  be  the  agent  or  cause  producing  this  condition.  It 
is  natural,  therefore,  that  all  drugs  capable  of  benumbing  the  sense  of 
pain  should  be  called  anesthetics.  As  a  matter  of  fact,  a  very  large 
number  of  substances  are  capable  of  producing  this  condition  of 
angesthesia,  either  when  inhaled,  when  taken  by  other  means  into  the 
body,  or  when  acting  locally  on  peripheral  nerves;  yet  a  great  majority 
of  these  possess  other  powers  which  prevent  us  from  using  them — that 
is,  they  are  lethal  if  not  used  very  carefully,  or  irritant,  or  cause  degen- 
erative changes  in  the  tissues.  Although  more  than  fifty  years  have 
elapsed  since  ether  and  chloroform  were  first  employed  as  anaesthetics, 
no  other  drugs  have  yet  been  discovered  which  even  remotely  approach 
them  in  general  usefulness,  notwithstanding  the  fact  that  both  these 
substances  possess  very  great  disadvantages.  As  a  matter  of  fact,  they 
are  the  only  two  drugs  generally  used  in  surgery  to-day  as  anaesthetics 
for  major  operations.  It  is  true  that  nitrous-oxide  gas  is  largely  used  by 
■dentists,  but  the  physician  and  surgeon  practically  never  use  it  because 
it  is  too  fleeting  in  its  eflrects,  and  because  the  apparatus  for  storing  it 
is  costly  and  cumbersome. 

Anaesthetic  Agents. — 80  far  as  the  surgeon  is  concerned,  the  anaes- 
thetic drugs  u'hicli  can  be  satisfactorily  employed  are  ether,  chloroform, 
and  bromide  of  ethyl,  named  in  the  order  of  their  popularity  and 
safety.  While  it  is  true  that  in  certain  parts  of  this  country  and  else- 
where cbloroform  is  used  to  the  exclusion  of  ether,  it  is  also  a  fact  that, 
iaking  tlio  world  at  large,  ether  is  most  widely  employed.     It  is  a  note- 

87 


88  A  TEXT-BOOK  OF   GYNECOLOGY 

worthy  fact  that  in  England  and  on  the  continent,  where  for  manjr 
years  chloroform  was  the  favourite  anesthetic,  ether  is  rapidly  grow- 
ing in  popularity  and  in  the  frequency  of  its  use.  Bromide  of  ethyl 
is  so  little  used  in  comparison  with  these  two  drugs  that  it  can  scarcely 
be  mentioned  with  them,  but  as  it  is  the  only  one  of  any  real  value 
besides  the  more  important  ones,  it  is  named  at  this  point. 

Relative  Safety  of  Ether  and  Chloroform. — The  bald  statement  can 
be  made  without  danger  of  correction  that,  as  a  rule,  ether  is  by  far 
the  safer  anesthetic  of  the  two  for  the  average  case.  Statistics  which 
are  stupendous  emphasize  this  fact,  and  it  is  as  certain  as  anything; 
human  can  be;  but  to  make  this  statement  without  the  additional  fact 
that  circumstances  alter  cases,  that  idiosyncrasy  or  disease  may  render 
it  safer  to  use  chloroform  than  ether,  would  be  unjust  to  an  impor- 
tant subject.  That  such  conditions  may,  and  in  abdominal  and  pelvic 
surgery,  especially,  do  exist  and  reverse  the  general  rule  just  laid  down,, 
is  as  certain  as  that  general  rule  itself. 

Race  and  Temperament  in  the  Selection  of  an  Anaesthetic. — Upon 
the  Anglo-Saxon  race  and  those  races  who  by  close  association,  habit,. 
and  environment,  are  similarly  affected  by  climate  and  other  causes,, 
ether,  as  a  rule,  acts  well,  provided  that  it  is  employed  properly  and 
that  the  temperature  of  the  atmosphere  is  moderately  cool.  The  pres- 
ence of  a  high  temperature,  such  as  is  met  with  in  hot  countries,  ren- 
ders it  impossible  to  use  ether  with  advantage,  and  makes  it  necessary 
to  use  chloroform.  Again,  it  would  seem  that  chloroform  acts  better 
upon  southern  peoples  than  upon  northerners,  and  these  facts  point 
an  explanation  for  the  strenuous  assertions  of  the  ether  advocate  and 
the  equally  forcible  statements  of  the  employer  of  chloroform.  Dog- 
matic statements  upon  both  sides  of  this  question  have  done  an  im- 
mense amount  of  harm.  They  have  clouded  the  judgment  of  the  pro- 
fession, they  have  given  medical  students  a  bent  which,  once  attained, 
has  persisted  all  their  lives,  and  finally  they  have  led  to  most  impor- 
tant legal  complications.  Hare  has  heard  a  great  teacher  tell  his. 
students  that  if  they  used  chloroform,  and  had  a  death  under  its  use, 
he  would  testify  that  the  death  was  avoidable;  and  he  is  continually 
meeting  men  so  influenced  by  those  teachings  of  years  ago  that  they 
do  not  use  chloroform  to-day  because  they  are  so  fearful  of  an  accident.. 
This  is  not  good  doctrine.  Every  one  who  uses  anesthetics  should 
employ  them  according  to  the  case  to  be  treated,  and  the  employment 
of  either  drug  to  the  exclusion  of  the  other  is  not  giving  the  patient 
or  the  physician  himself  all  the  chance  for  good  results  that  is  due- 
to  them.  Yet  at  the  present  time  these  drugs  are  used  by  habit  or  rou- 
tine to  an  extent  that  is  unwise.  There  are  as  many  reasons  for  using- 
a  given  anesthetic  as  a  given  drug  in  place  of  another,  for  there  are- 
indications  and  contraindications  governing  the  use  in  either  case. 

Indications  and  Contraindications  for  the  Use  of  Ether  and  Chloro- 
form.— Beginning,  then,  with  a  consideration  of  the  most  important, 
drug — ether — and  believing  that  it  is  the  anesthetic  best  suited  to  a. 


ANiESTIIETICS  AND  ANAESTHESIA  IN  GYNECOLOGY  80 

majority  of  cases,  what  are  the  factors  which  render  its  use  inadvisable 
in  a  given  case?  In  the  first  place,  its  local  effect  upon  the  upper  and 
lower  respiratory  tract  is  a  distinct  disadvantage  in  all  cases,  and  the 
presence  of  a  pre-existing  irritation  in  these  parts  renders  it  very  often 
a  dangerous  angesthetic.  To  it  are  credited  the  production  of  severe 
attacks  of  bronchitis,  pneumonia,  and  pulmonary  oedema,  and  it  is 
undoubtedly  responsible  for  these  sequelaa  in  some  instances.  The 
question  is,  How  often  is  the  irritation  of  the  ether  inhalation  the  real 
factor  in  the  production  of  these  states?  Hare  believes  it  to  be  very 
rarely  so,  except  in  susceptible  children  and  old  people,  and  in  persons 
v/ho  have  an  idiosyncrasy  to  its  use.  In  a  large  number  of  the  cases  the 
respiratory  difficulties  after  etherization  are  due  to  exposure  to  cold, 
and  very  slightly,  if  at  all,  to  the  ether.  This  is  a  fact  overlooked  to  an 
extent  which  is  almost  criminal  in  its  negligence.  There  is  not  a  reader 
of  this  chapter  who  has  not  seen  patients  stripped  of  nearly  all  cover- 
ing but  a  sheet  or  shirt,  and  exposed  for  a  long  period,  while  some 
great  heat  citadel  of  the  body,  such  as  the  abdominal  cavity,  is  ex- 
posed or  even  opened  to  the  general  air  of  the  room.  ISTot  one  of  them 
but  knows  that  the  abdominal  wall  is  the  first  to  feel  exposure,  and  that 
the  great  vessels  and  abdominal  organs  are  the  heat  distributors  and 
centres  of  heat  in  the  body;  and  yet  even  in  the  best  operating  rooms, 
the  abdominal  cavity,  the  natural  temperature  of  which  is  about  103° 
F.,  is  exposed  to  an  atmosphere,  warmed,  it  is  true,  but  even  when  at  90° 
F.,  still  thirteen  degrees  colder  than  the  belly  contents.  Further,  the 
lumbar  region,  the  back  and  the  buttocks,  are  often  lying  in  a  puddle 
of  liquid  for  many  minutes.  There  are  few  surgeons  who  could  them- 
selves survive  such  exposure  without  ill  effect.  It  is  true  that  ether 
helps  the  temperature  to  fall  by  its  evaporation  and  its  consequent 
abstraction  of  heat,  by  aiding  the  dissipation  of  heat  by  its  effect 
on  the  vessels,  and  by  affecting  the  nervous  mechanism  of  heat  regu- 
lation, bat  these  other  factors  aid  it  also.  Many  years  ago  Hare  re- 
ported a  series  of  observations  upon  this  subject,  which  showed  that 
these  assertions  are  true. 

Ether  in  its  Relation  to  Bodily  Temperature. — In  the  lower  animals 
a  fall  of  temperature  under  profound  etherization  may  amount  to  as 
many  as  8°  to  10°  F.,  and  in  man  it  is  by  no  means  uncom- 
mon to  observe  a  fall  of  as  much  as  three  degrees  below  normal,  the 
fall  being  influenced  somewhat  by  the  part  of  the  body  operated  upon. 
In  thirteen  cases  taken  at  random  the  greatest  fall  was  4.4°  and 
the  lowest  1.2°  F.  There  can  be  no  doubt  that  much  of  the  renal  con- 
gestion and  respiratory  disorder  met  with  after  operations  would  be  set 
aside  if  the  patient  was  supplied  with  heat  during  the  use  of  the 
anaesthetic,  rather  than  after  he  is  put  back  to  bed. 

Without  any  desire  to  defend  ether  from  the  assertion  that  its 
respiratory  effects  are  somewhat  banc^ful,  let  us  then  be  sure  that  it  is  at 
fault  in  a  given  case  before  discrcfliting  its  claim  to  usefulness. 

Again,  otfier  is  often  given  in  a  manner  which  is  improper  in  more 


90  A  TEXT-BOOK  OP  GYNECOLOGY 

ways  than  one.  Partly  because  the  youthful  assistant  who  gives  the 
angesthetic  is  desiroiis  of  being  quick  in  his  work,  partly  because  his 
superior  is  often  urging  him  to  hurry  the  patient  into  the  operating 
room,  the  drug  is  poured  too  freely  upon  the  inhaler  and  the  inhaler 
held  too  closely  to  the  patient's  face,  with  the  result  that  the  ether 
vapour  comes  in  concentrated  form  upon  mucous  membranes  not  pre- 
pared to  receive  it,  which  causes  a  profuse  outpouring  {21ie7-apeutic 
Gazette,  1888,  p.  317)  of  secretion,  accompanied  with  struggling  and 
cj^anosis.  Any  assistant  whose  patient  struggles  in  the  first  stage  of 
the  anaesthetizing  process  is  not  performing  his  function  properly. 
The  early  stage  should  be  sufficiently  prolonged  to  produce  quietly 
the  so-called  primary  angesthesia,  and  the  inhaler  should  be  gradually 
brought  nearer  and  nearer  to  the  patient  as  the  effect  of  the  drug  is 
momentarily  increased.  By  this  means  evil  dreams  or  delusions  in  the 
later  stages  are  often  avoided.  If  a  patient  sinks  into  unconsciousness 
under  the  firm  mental  impression  that  she  is  being  choked  to  death, 
the  dreams  that  follow  are  not  apt  to  be  joyful.  Aside  from  the  trou- 
blesome struggling  later  on  in  anesthesia,  it  should  be  recalled  that 
the  nervous  shock  of  such  a  sensation  and  svich  dreaming  is  a  severe 
strain  upon  the  patient's  nervous  system.  An  ordinary  nightmare  is 
sufficiently  disturbing,  but  a  real  operation  added  to  it,  preceded  by  a 
conscious  period  of  fright,  is  a  terrible  combination  of  nerve-straining 
elements.  It  is  for  this  reason  in  part  that  physicians  are  continually 
seeing  patients  who,  having  left  the  surgeon's  hands  as  "  operative  re- 
coveries," are  physical  wrecks. 

Even  if  ether  is  given  properly  it  may  produce  evil  effects,  as  already 
stated,  and  in  general  terms  it  may  be  considered  that  known  idiosyn- 
crasies to  its  effects  from  former  accidents  or  sequela?,  acute  and  chronic 
bronchitis,  nephritis  in  all  its  forms,  but  particularly  in  its  acute  and 
parenchymatous  forms,  and  laryngeal  infiammations,  render  chloro- 
form the  preferable  drug.  In  all  cases  in  which  the  surgeon  has  control 
of  his  patients  for  any  length  of  time  before  the  operation  a  careful 
examination  of  the  urine  should  be  made.  Not  only  sho^ild  albumin 
and  cysts  be  sought  for,  but  several  estimations  of  the  amount  of  urea 
excreted  in  twenty-four  hours  should  be  made,  since  this  will  oftentimes 
reveal  renal  inadequacy  or  diseases  which  may  be  exaggerated  by  the 
aneesthetic  and  cause  complications  which  are  undesirable  and  dan- 
gerous. 

Again,  in  the  presence  of  marked  atheromatous  degenerations  of  the 
arteries,  of  aneurism,  and  abdominal  inflammation,  chloroform  is  the 
better  angesthetic,  since  it  lowers  rather  than  raises  blood  pressure  and 
does  not  cause  struggling,  as  does  ether,  and,  therefore,  is  not  so  apt 
to  cause  apoplexy,  nor  is  vomiting  so  apt  to  follow  its  use. 

On  the  other  hand,  if  any  dilatation  of  the  heart  or  degeneration, 
of  its  walls  and  severe  valvular  leakage  is  present,  then  ether  is  the 
safer  drug. 

There  are  operative  reasons  for  choosing  one  angesthetic  in  prefer- 


ANESTHETICS  AND   ANESTHESIA  IN  GYNECOLOGY  91 

ence  to  the  other  which  are  almost  as  important  as  those  Just  given. 
Other  things  being  equal,  and  the  anaasthetizer  being  skilled  in  the  use 
of  chloroform,  this  drug  is  often  superior  to  ether  in  that  it  does  not  so 
frequently  cause  vomiting,  which,  if  severe,  may  be  disadvantageous  in 
abdominal  operations.  It  must  be  borne  in  mind,  however,  that  if 
proper  ante-operative  procedures  are  taken  and  ether  is  given  with  care 
and  with  oxygen,  vomiting  can  often  be  entirely  avoided,  and  ether  is 
the  drug  of  preference  in  the  majority  of  cases  in  cool  climates. 

Choice  of  Anaesthetic  for  Children. — There  can  be  no  doubt  that  in 
very  young  children  ether  may  cause  considerable  bronchitis,  some- 
times associated  with  such  an  outpouring  of  mucous  liquid  that  a  state 
approaching  suffocative  catarrh  is  developed.  Chloroform,  if  properly 
given,  does  not  do  this.  Not  only  is  this  true,  but  it  is  also  a  fact  that 
very  young  children  have  a  certain  amount  of  immunity  from  the  lethal 
effects  of  chloroform.  There  are  few  instances  on  record  of  death  from 
chloroform  in  j^oung  children,  and  this  fact,  combined  with  the  avoid- 
ance of  respiratory  irritation  and  the  early  struggling  produced  by 
ether,  renders  it  wise  in  many  instances  to  employ  chloroform. 

Bromide  of  Ethyl — Indications  and  Contraindications. — The  ques- 
tion may  well  be  asked.  Under  what  circumstances  is  it  proper  to  use 
bromide  of  ethyl?  Before  answering  this  question,  it  must  be  recalled 
that  this  drug  is  even  yet  under  a  cloud,  and  has  not  reached  a  degree 
of  popular  favour  which  makes  the  uninitiated  feel  like  trying  it. 
This  state  of  affairs  depends  upon  several  factors.  In  the  first  place, 
the  early  attempts  made  to  introduce  it  into  practice  in  this  country 
were  productive  of  catastrophes  which  frightened  the  surgeons  using 
it  sufficiently  to  make  them  give  up  its  employment,  and  incidentally 
alarmed  those  who  had  not  3^et  attempted  its  use.  The  use  of  a  new 
and  untried  drug  followed  by  an  accident  would  naturally  impose 
upon  the  medical  man  an  increased  load  of  blame,  yet  the  occurrence 
by  coincidence  of  such  accidents  when  the  drug  was  first  used,  is  no 
reason  for  condemning  the  drug  as  too  unsafe  to  Avarrant  its  adminis- 
tration. The  very  fact  that  the  ansesthetizer  did  not  know  how  best 
to  give  it  rendered  it  more  likely  to  act  badly  than  when  it  was  skilfully 
used,  and  in  all  probability  the  preparation  of  the  drug  employed  may 
not  have  been  pure.  The  writer  has  often  wondered  how  long  the  use 
of  ether  or  chloroform  might  have  been  delayed  had  the  first  patients 
placed  under  their  influence  died,  a  possibility  by  no  means  remote, 
because  those  patients  might  perchance  have  had  hearts  unfit  for  the 
use  of  those  drugs.  If,  for  example.  Sir  James  Simpson's  "  chloroform 
party  "  had  ended  in  a  chloroform  catastrophe,  one  or  more  of  them 
never  coming  back  to  life,  what  an  unjust  blow  would  have  been  given  to 
a  most  useful  drug,  and  who  would  have  felt  like  repeating  the  test! 

As  a  matter  of  fact,  a  certain  number  of  deaths  have  been  recorded 
as  having  been  caused  by  bromide  of  ethyl  (see  page  95  for  possible 
causes),  and  there  can  bo  no  doubt  that  it  is  capable  of  causing  death 
if  Ini'lly  given  to  a  |>atient  unfit  for  its  use.     The  important  questions 


92 


A  TEXT-BOOK  OF   GYNECOLOGY 


are,  whether  it  is  safe  enough  to  justify  its  common  use,  and  whether 
it  fulfils  any  indications  not  so  well  filled  by  ether  and  chloroform. 
The  answer  to  botn  these  questions  is  in  the  affirmative.  The  drug  has 
been  given  many  thousand  times  without  ill  effects  and  deserves  a 
place  in  the  hands  of  the  gynecological  operator  and  obstetrician.  Cer- 
tain perfectly  proper  and  easily  taken  precautions  are  essential  for  its 
satisfactory  use  (see  page  95).  The  indications  for  its  employment 
are  sufficient  and  numerous.  The  first  of  these  is  met  with  when  we 
desire  to  employ  a  rapidly  acting,  agreeable,  and  fleeting  angesthetie 
for  the  performance  of  short  operations,  such  as  curetting  and  dilat- 
ing the  uterus,  and  in  making  painful  examinations.  When  properly 
given,  bromide  of  ethyl  produces  anesthesia  almost  as  rapidly  as 
nitrous  oxide,  and  when  it  is  stopped  the  patient  returns  to  conscious- 
ness almost  as  speedily  as  when  the  gas  is  given,  and  without  any 
nausea,  vomiting,  dizziness,  or  other  ill  efl^ects.  It  lends  itself,  there- 
fore, to  a  large  number  of  cases  in  and  out  of  the  gynecologist's  office, 
and  deserves  greater  use.  There  are  two  disadvantages  connected  with 
its  employment — first,  that  there  may  be  muscular  tonic  contraction 
or  rigidity,  which  is  annoying,  and  may  render  efforts  at  examination 
or  operation  difficult  until  it  is  overcome;  and,  secondly,  that  it  is 
apt  to  leave  a  garlicky  odour  on  the  breath — two  objections  of  compara- 
tively small  moment,  after  all.  The  drug  is  not  suitable  for  pro- 
longed operations. 

The  Administration  of  Ether. — The  anresthetizer,  like  the  operator, 
knows  that  the  simpler  the  instrument  the  easier  the  performance  of 

the  duty  before  him,  and  as  a  re- 
sult there  are  but  two  forms  of 
ether  inhalers  commonly  employed 
in  the  United  States,  and  these 
meet  the  needs  of  the  case  so  well 
that  nothing  else  need  be  consid- 
ered. The  one  is  the  folded  towel, 
turned  into  a  well-made  cone, 
stiffened,  it  may  be,  with  a  sheet 
of  heavy  paper  or  cardboard  be- 
tween its  folds,  and  fitted  in  the 
apex  with  a  small,  clean,  and  ster- 
ile sponge  or  piece  of  absorbent 
cotton,  to  hold  the  anaesthetic 
fluid.  For  this  may  be  substituted 
the  Allis  inhaler,  which  is  a  cylin- 
drical or  ovoid  cover  around  a 
grated  case,  from  the  gratings  of 
which  layers  of  cotton  cloth  pass 
from  side  to  side  (Fig.  29).  The  air  passes  freely  between  the  layers 
of  cloth,  which,  being  wet  with  ether,  load  the  inspired  air  with 
anaesthetic  vapour.     If  made  of  metal,  so  that  it  can  be  boiled  after 


Fig.  29.—"  The  Allis  inhaler,  which  is  a  cy- 
lindrical or  ovoid  cover  around  a  grated 
case,  from  the  gratings  of  which  layers 
of  cloth  pass  from  side  to  side." — Haee. 


ANESTHETICS  AND  ANJllSTHESIA  IN   GYNECOLOGY  93 

each  use,  and  kept  rigidly  clean,  this  is  the  best  inhaler  on  the  market, 
because  it  gives  plenty  of  ether  and  it  permits  a  view  of  the  face 
of  the  patient.  Both  the  simple  cone  and  the  Allis  inhaler  can  be 
employed  when  it  is  desired  to  give  oxygen  gas  with  the  anaesthetic, 
since  the  gas  can  be  delivered  to  the  patient  by  means  of  a  soft  tube 
slipped  under  the  edge  of  the  cone  close  to  the  patient's  nose. 

The  Administration  of  Mixed  Vapours  for  Anaesthetic  Purposes. — • 
There  are  several  somewhat  complex  forms  of  apparatus  on  the  market 
for  giving  ether  and  oxygen  gas  or  chloroform  and  oxygen  gas.  Hare 
considers  none  satisfactory  in  every  respect.  In  all  forms  which  he  has 
seen,  the  oxygen  is  made  to  bubble  through  the  ether  or  the  chloroform, 
thereby  vaporizing  the  ansesthetic,  and  a  mixture  of  oxygen  gas  and 
of  the  anaesthetic  vapour  is  then  conveyed  through  a  tube  to  the  in- 
haler, which  is  placed  over  the  patient's  nose  and  mouth.  There  are 
several  disadvantages  inseparable  from  this  method  of  using  this  valu- 
able combination  of  therapeutic  agents.  The  first  objection  is  that  it 
is  impossible  to  increase  or  decrease  the  quantity  of  oxygen  gas  supplied 
to  the  patient  without  at  the  same  time  increasing  or  decreasing  the 
quantity  of  ether  or  chloroform,  and  conversely  the  quantity  of  these 
agents  can  not  be  verified  without  the  supply  of  oxygen.  Manifestly,  an 
inability  to  make  suitable  variations  in  the  quantity  of  these  various 
agents  is  distinctly  disadvantageous.  As  an  illustration  of  how  disad- 
vantageous it  may  be,  Hare  mentions  the  fact  that  an  eminent  surgeon 
complained  to  him  that  a  grave  difficulty  in  the  use  of  oxygen  and  ether 
lay  in  the  long  period  of  time  required  to  get  the  patient  under  the 
anaesthetic.  The  cause  of  this  delay  was  without  doubt  due  to  the 
fact  that  if  large  quantities  of  oxygen  were  passed  through  the  ether 
with  the  purpose  of  conveying  considerable  amounts  of  the  anaesthetic 
to  the  patients,  the  individual  also  received  such  large  quantities  of 
oxygen  that  a  condition  of  physiologic  apnoea,  or  shallow  or  arrested 
breathing,  occurred  through  sedation  of  the  respiratory  centres.  As 
soon  as  this  sedation  took  place  the  patient  breathed  less  deeply  than 
before,  or  she  stopped  breathing  entirely,  and  under  these  circum- 
stances took  but  little  anfesthetic  vapour  into  the  lungs,  and  so  passed 
very  slowly,  if  at  all,  under  its  influence.  In  Hare's  opinion,  therefore, 
the  proper  way  to  use  oxygen  by  inhalation,  in  conjunction  with  the 
anaesthetic,  is  to  place  the  drum  upon  whatever  form  of  inhaler  the 
physician  desires  to  employ,  and  to  carry  into  the  inhaler  the  oxygen 
gas  direct  from  the  bag,  which  is  usually  attached  to  the  steel  cylinder 
containing  the  gas.  Under  these  circumstances  the  patient  receives 
both  the  anaesthetic  and  the  oxygen,  each  of  which  can  be  increased 
in  quantity,  according  to  his  needs,  with  the  result  that  he  can  be 
speedily  anaistbetized  and  yet  receive  all  the  oxygen  that  is  necessary 
to  prevent  any  of  the  disagreeable  symptoms  of  anaesthetization  and  its 
disagreeable  sequelae.  Such  a  plan  has  the  added  advantage  that  it  is 
simple  and  does  not  require  any  additional  apparatus,  the  rubber  tube 
ffoni  ilio  oxygen  cylinder  passing  under  the  edge  of  the  inhaler  placed 


94:  A  TEXT-BOOK  OF  GYNECOLOGY 

upon  the  patient's  face,  and  the  supply  of  gas  being  governed  by  the 
stopcock  on  the  cylinder. 

One  of  the  forms  of  apparatus  which  is  usually  sold  for  the  simul- 
taneous administration  of  oxygen  and  ether  consists  in  an  inhaler 
which  covers  the  patient's  nose  and  mouth  and  prevents  him  from 
getting  any  atmos23heric  air,  with  the  result  that  he  is  forced  to  breathe 
nothing  but  pure  oxygen,  mixed  with  angesthetic  vapour.  In  order  to 
make  this  still  more  complete,  a  large  rubber  bag  is  attached  to  the 
inhaler,  which  has  no  connection  with  the  outside  air,  and  which  is 
inflated  with  each  expiration  of  the  patient  and  dilated  with  each  inspi- 
ration. After  a  very  few  respiratory  movements  the  patient  is  there- 
fore receiving  a  mixture  of  oxygen  angesthetic  and  devitalized  air,  the 
quantity  of  the  latter  increasing  with  each  subsequent  respiration. 
Manifestly  this  method  has  two  grave  objections:  First,  that  the  pa- 
tient is  supplied  with  pure  oxygen  instead  of  with  atmospheric  air, 
whereas  Nature  provides  healthy  human  beings  with  a  mixture  of  oxy- 
gen and  nitrogen.  The  other  disadvantage  is  that  the  patient  is  con- 
tinually taking  back  into  his  lungs  impurities  which  he  ought  to  be 
getting  rid  of. 

That  the  administration  of  oxygen  gas  with  ether  or  chloroform  is 
a  distinctly  advantageous  procedure  can  not  be  doubted.  The  pulse 
under  both  ansesthetics  when  the  gas  is  given  remains  in  good  condi- 
tion in  a  majority  of  cases,  and  there  are  no  complications  or  sequela3 
in  the  shape  of  depressions,  nausea,  or  vomiting.  Feeble  circulation 
and  respiratory  disorders  are  much  less  frequently  met  with  if  oxygen  is 
given  than  if  it  is  not  administered.  Further  than  this,  the  progress  of 
the  patient  during  the  anji^sthetic  period  is  usually  peaceable,  cyanosis 
being  largely  avoided. 

The  Administration  of  Chloroform. — For  the  administration  of  chlo- 
roform even  more  apparatus  has  been  invented  than  for  the  giving  of 
ether.  Much  of  it  is  extremely  complicated,  possessing  this  disadvan- 
tage in  addition  to  others  which  need  not  be  considered  in  the  brief 
space  devoted  to  this  article.  While  it  is  true  that  many  of  the  English 
ansesthetizers  employ  these,  American  physicians  are  usually  content 
with  much  simpler  apparatus.  There  are,  practically  speaking,  only 
two  chloroform  inhalers  that  can  be  generally  employed  with  advan- 
tage— namely,  that  of  Esmarch  and  that  of  Lawrie.  Both  of  these 
inhalers  embody  two  essentials  of  every  form  of  apparatus  used  for  the 
giving  of  chloroform — namely,  the  free  access  of  air  to  the  patient. 
All  the  more  complicated  inhalers  are  lacking  in  this  important  char- 
acteristic, or  depend  upon  valves  which  may  get  out  of  order.  The 
majority  of  anaesthetizers  in  this  country  employ  a  folded  napkin  or  one 
of  the  inhalers  just  named.  The  patient  should  get  at  least  ninety  per 
cent  of  air  during  the  use  of  the  chloroform.  Great  advantages  in  the 
Esmarch  and  Lawrie  inhalers  are  the  facts  that  a  free  supply  of  air  is 
present;  too  much  of  the  drug  can  not  be  poured  upon  the  inhaler  with- 
out escaping,  so  that  the  patient  can  not  receive  an  overdose,  except 


ANAESTHETICS  AND  ANAESTHESIA  IN   GYNECOLOGY 


95 


through  gross  negligence;  and  the  face  of  the  patient  is  readily  seen. 
Whatever  the  form  of  inhaler  used,  it  must  never  be  held  so  tightly 
over  the  patient's  face  that  air  is  cut  off 
(Fig.  30). 

The  Lawrie  inhaler  is  so  cheap  that  a 
new  one  can  be  used  for  each  patient,  and 
the  thin  flannel  cover  of  the  Esmarch 
can  be  boiled  each  time  it  is  used,  thereby 
insuring  sterilization. 

When  chloroform  is  given  it  must 
be  placed  on  the  inhaler  in  drops,  and 
not  poured  on  freely  as  one  uses  ether. 

Finally,  the  angesthetizer  should  re- 
member that  the  dose  of  the  anaesthetic 
is  not  that  which  he  pours  on  the  inhaler 
so  much  as  the  amount  that  the  patient 
takes  into  his  lungs,  and,  therefore,  that 
in  all  cases  the  attention  of  the  anaasthet- 
izer  should  be  centred  on  the  respira- 
tion, for  upon  the  rapidity  and  depth  of 
tills  function  does  the  dose  depend. 
Again,  as  the  respiratory  function  is  the 
first  one  to  feel  the  depressing  effects  of 
the  drug,  it  acts  as  a  good  index  of  the 
degree  of  influence.  In  a  case  where  the 
heart  is  known  to  be  diseased,  this  organ 

must,  of  course,  be  watched  also.  Should  the  respiratory  action  become 
irregular  or  stormy,  the  ansesthetizer  should  at  once  stop  the  anaes- 
thetic, since  the  irregularity  indicates  abnormal  action  of  the  drug, 
and  the  amount  inhaled  can  not  be  estimated. 

The  Administration  of  Bromide  of  Ethyl. — When  bromide  of  ethyl 
is  given,  it  should  be  placed  upon  a  cone  or  inhaler  which  tightly  fits 
the  face,  and  be  pushed  freely  until  the  patient  passes  under  its  effect, 
which  will  be  rapidly  accomplished,  as  a  rule.  Care  must  be  taken 
that  the  bromide  of  ethylene  is  not  used  by  mistake,  and  that  the  drug 
is  kept  in  dark  glass  bottles  to  prevent  its  decomposition.  In  order  to  be 
sure  of  its  purity,  it  is  best  to  use  the  drug  from  hermetically  sealed 
flasks. 

Management  of  Respiratory  and  Other  Accidents  in  Anaesthesia. — 
Attention  may  be  called  to  the  use  of  two  instruments  commonly  em- 
ployed by  inexperienced  anassthetizers,  which  are  nearly  always, 
abused,  viz.,  the  mouth  gag  and  tongue  forceps.  The  mouth  gag  aids, 
rather  than  prevents,  the  falling  of  the  tongue  back  into  the  mouth,  and 
increases  the  possibility  of  the  inhalation  of  saliva  or  other  materials 
into  the  lungs;  and  the  tongue  forceps  is  almost  invariably  so  con- 
structed that  it  bruises,  punches,  or  punctures,  the  tongue  in  a  manner 
that  is  anything  but  wise.     Inexperienced  anacsthetizers  are  very  apt 


Fig.  30. — Esmarch's  chloroform 
inhaler. — Haee. 


96  A  TEXT-BOOK  OF   GYNECOLOGY 

to  believe  that  these  two  instruments  should  always  be  in  their  pocket, 
and  should  be  frequently  employed.  As  a  matter  of  fact,  they  are  very 
rarely,  if  ever,  needed,  and  the  jDroper  manipulation  of  the  head  and 
jaw,  and  grasjjing  the  tip  of  the  tongue  with  the  fingers  which  have 
been  covered  with  a  towel,  are  quite  sufficient  to  produce  the  proper 
position  of  this  organ. 

There  is  a  common  error  in  the  method  of  manipulating  the  head 
and  jaw  in  respiratory  accidents  under  anesthetics.  Under  such  cir- 
cumstances it  is  the  custom  to  allow  the  patient's  head  to  fall  backward, 
so  that  the  muscles  in  the  anterior  i)ortion  of  the  neck  are  in  a  condition 
of  great  extension,  and  it  is  thought  that  by  maintaining  this  posture 
the  glottis  is  widely  opened  so  that  air  can  readil}^  pass  in  and  out  of  the 
lungs.  It  is  true  that  this  position  of  the  head  does  widely  open  the 
glottis,  but  at  the  same  time  it  drops  the  soft  palate  down  upon  the  dor- 
sum of  the  tongue  in  such  a  way  that  the  patient  is  required  to  take  all 
the  air  that  he  needs  through  his  nasal  chambers.  These  upper  air- 
passages  are  nearly  always  obstructed  by  mucus,  which  has  been 
brought  out  as  a  result  of  the  local  irritation  produced  by  the  anges- 
thetic  vapour.  In  addition,  the  nasal  passages  of  many  patients  are 
partially  or  totally  occluded  by  overgrowth  of  the  mucous  membrane 
covering  the  turbinated  bones  or  by  the  presence  of  ^oolypi,  so  that  if 
any  of  these  causes  of  obstruction  are  present  it  is  most  difficult  for  the 
patient  to  get  air.  If,  on  the  other  hand,  the  angesthetizer,  standing 
at  the  patient's  head  in  his  usual  position,  places  a  hand  upon  each 
side  of  the  head  and  jaw  in  such  a  way  that  the  palm  of  the  hand 
covers  each  ear  and  the  tip  of  the  middle  finger  rests  under  the  angle 
of  the  jaw,  and  then  draws  the  head  toward  him,  stretching  the  neck  of 
the  patient,  and  at  the  same  time  carries  the  head  forward  instead  of 
backward,  the  result  is  that  the  glottis  is  quite  as  Avidely  opened  as 
when  the  head  is  extended  upon  the  neck  and  carried  backward,  with 
the  additional  advantage  that  the  soft  palate  is  not  strapped  over  the 
dorsum  of  the  tongue,  and  the  patient  can,  therefore,  obtain  air  both 
through  his  mouth  and  nasal  chambers.  The  attitude  of  the  head 
under  these  circumstances  in  relation  to  the  rest  of  the  body,  save  for 
the  fact  that  the  patient  is  prone  rather  than  erect,  is  that  which  is 
taken  by  the  athlete  when  running.  Surely  no  runner  desiring  to  fill 
his  lungs  with  air  would  tip  his  head  far  l^ack  with  his  chin  pointed 
upward,  but,  on  the  other  hand,  would  project  his  head  forward  in  such 
a  way  as  to  make  his  upper  passages  as  patulous  as  possible. 

Anaesthetic  Mixtures. — There  are  three  ansesthetic  mixtures  to 
which  reference  should  be  made  before  leaving  this  subject.  One  of 
these  is  the  so-called  A.-C.-E.  mixture,  which  contains  alcohol,  chloro- 
form, and  ether,  this  combination  being  made  with  the  idea  of  securing 
the  auEesthetic  effect  by  three  drugs;  and  of  combating  by  the  alcohol 
and  ether  any  tendency  to  cardiac  depression  produced  by  the  chloro- 
form. Theoretically  this  mixture  has  something  to  recommend  it,  but 
practically  the  rapidity  of  vaporization  of  these  three  drugs  is  so  dif- 


ANESTHETICS  AND   ANJ^:STHESIA  IN  GYNECOLOGY  97 

f  erent  that  the  patient  will  get  first  one  anaesthetic  and  then  the  other, 
and  finally  the  alcohol,  so  that  in  reality  he  does  not  pass  under  the 
influence  of  all  three  at  once.  It  can  not  be  urged  that  there  are  serious 
objections  to  this  mixture,  but,  on  the  other  hand,  there  are  no  material 
advantages  in  it.  The  same  objection  holds  against  the  C.-E.  mixture, 
which  contains  chloroform  and  ether  alone. 

The  last  anaesthetic  mixture  which  need  be  mentioned  is  Schleich's, 
which  is  made  according  to  three  formulas,  differing,  not  in  ingredients, 
but  in  the  quantity  of  each  ingredient,  and  which  consists  in  a  mixture 
of  ether,  chloroform,  and  petroleum  ether.  It  is  claimed  by  Schleich 
that  the  petroleum  ether  has  no  deleterious  effects.  He  believes  that 
the  effect  of  chloroform  and  sulphuric  ether,  together  with  the  addition 
of  petroleum  ether,  prevents  the  disagreeable  effects  which  are  met  with 
when  chloroform  or  ether  is  given  alone.  While  this  mixture  on  its 
first  apj^earance  received  considerable  attention,  increasing  clinical  ex- 
perience has  not  been  favourable  to  its  employment,  and  it  is  speed- 
ily dropping  out  of  use  even  in  the  hands  of  those  who  first  considered 
it  of  great  value. 

Central  Anaesthesia  by  Cocaine. — In  1885  spinal  ansesthesia  was 
practised  by  J.  Leonard  Corning,  of  New  York.  Tuffier  utilizes  it  in 
the  following  way:  A  2-j)er-cent  solution  of  cocaine  is  sterilized  by 
heating  at  80°  C,  the  sterilization  being  repeated  each  day  for  three 
consecutive  days.  This  solution  is  thrown  into  the  arachnoid  space  of 
the  spinal  cord  by  means  of  a  sterilized  hypodermic  syringe  with  a  long 
and  heavy  needle.  To  administer  the  injection  a  line  is  drawn  from 
the  crest  of  one  ilium  to  the  other.  The  forefinger  of  the  left  hand  is 
placed  on  the  spine  of  the  vertebra  immediately  above  the  line  just 
indicated.  The  detached  needle  of  the  hypodermic  syringe  is  now 
inserted  to  the  right  and  a  little  above  the  tip  of  the  left  forefinger, 
being  pushed  well  into  the  spinal  canal.  The  escape  of  the  arachnoid 
fluid  will  indicate  that  the  needle  has  entered  the  canal.  The  loaded 
barrel  of  the  syringe  is  now  attached  to  the  needle  through  which  the 
solution  of  cocaine  is  discharged  slowly  and  without  force.  From  1.5 
to  3  cubic  centimetres  of  the  fluid  are  used,  the  dose  depending  some- 
what upon  the  size  of  the  patient.  Anaesthesia  from  the  diaphragm  to 
the  toes  will  develop  in  from  ten  to  twelve  minutes;  and  the  insensibil- 
ity thus  induced  will  last  from  one  to  three  hours.  The  cardiac  dis- 
turbance induced  by  this  form  of  anaesthesia  is  less  than  that  from 
either  ether  or  chloroform.  Ko  fatalities  have  been  accredited  to  it. 
A.  Palmer  Dudley  and  other  American  surgeons  have  utilized  this  form 
of  central  ana-stliesia  with  success  in  hysterectomy  and  other  equally 
severe  opei-ations.     It  is  es])ecially  eligible  in  kidney  complications. 

General  Anaesthesia  by  Alcohol. — It  is  practicable  to  bring  patients 
itilo  ;i  ((itidil  ion  of  surgical  ana>sthesia  by  the  administration  of  alco- 
hol. J.  .M.  Matthews,  of  Louisville,  frequently  operates  painlessly  for 
hemorrlioids  and  other  rectal  conditions  in  ])atients  who  are  thus 
^' dead  di-imk/'  'i'lic  alcohol  should  he  given  in  doses  of  an  ounce 
8 


98  A  TEXT-BOOK  OF  GYNECOLOGY 

every  few  minutes  until  alcoholic  coma  is  induced.  It  is  an  eligible  ex- 
pedient in  alcoholic  habitues,  but  is  liable  to  induce  an  aggravating 
acute  gastritis  with  attendant  vomiting  in  patients  who  are  not 
drinkers. 

General  Anaesthesia  by  Hypnosis. — The  researches  of  Charcot,  and 
later  of  the  Medical  School  of  Nancy,  have  established  the  possibil- 
ity of  entirely  destroying  physical  sensibility  by  suggestion.  Reed 
has  operated  for  the  repair  of  lacerated  perineum,  and  for  pelvic  abscess 
by  vaginal  drainage,  in  patients  who  had  been  rendered  unconscious 
by  hypnotic  angesthesia.  This,  however,  is  not  to  be  looked  upon 
as  an  agent  or  influence  of  general  utility,  for  the  reason  that  women 
are  not  all  subjective,  and  for  the  further  reason  that,  notwith- 
standing there  are  no  reflex  manifestations  of  pain,  nor  any  memory 
of  the  operation,  it  still  seems  that  the  impression  registered  upon  the 
secondary  or  induced  consciousness  provokes  shock  to  a  degree  that 
is  not  realized  under  general  ana?sthesia  as  ordinarily  practised.  The 
subject  is  one  pregnant  with  great  j)0ssibilities,  and  should  be  subjected 
to  more  critical  study  than  has  yet  been  accorded  it  by  the  English- 
speaking  medical  profession. 

Local  Anaesthesia. — It  is  sometimes  desirable  and  even  imperative 
to  avoid  the  administration  of  general  anaesthetics.  Pain  may  be  re- 
lieved under  such  circumstances  by  benumbing  the  parts  with  cold  or 
with  ether,  or  by  using  a  subcutaneous  injection  of  a  8-per-cent 
solution  of  cocaine.  The  latter  remedy,  however,  should  not  be  looked 
upon  as  innocuous,  so  far  as  its  constitutional  efl^ects  are  concerned, 
serious  cardiac  and  respiratory  complications  having  ensued  upon  the 
administration  of  but  a  small  quantity. 


CHAPTER    XII 

ABDOMINAL  SECTION 

Terminology — Preliminary  treatment  of  the  patient — The  evil  of  hypercatharsis — 
Examination  of  the  urine — Instruments — Preparation  of  the  field  of  operation 
— Location  of  the  incision — Direction  and  varieties  of  the  incision:  Vertical 
median,  transverse  umbilical,  transverse  suprapubic,  oblique  ventral,  inguinal, 
oblique  subcostal,  lumbo-iliac,  lumbo-costal — General  observations  on  making 
the  incision — Closure — Immediate  and  complete  by  laminated  suture — Where 
drainage  is  necessary  by  suture  en  masse — Drainage. 

Theee  has  been  much  discussion  of  the  various  terms  which,  from 
time  to  time,  have  been  coined  to  designate  the  operation  whereby  the 
abdominal  cavity  is  opened  and  its  viscera  made  accessible  for  surgical 
purposes.  Blancard,  of  Middleburg,  Zealand,  published  a  work  nearly 
two  hundred  years  ago  in  which  he  employed  the  word  "  gastrotomia  " 
to  designate  "  the  cutting  open  of  the  abdomen  and  womb,  as  in  sedio 
Ccesarea."  The  word  comes  from  two  Greek  terms — namely,  yao-r^p, 
meaning  belly  or  stomach,  and  rofiij,  meaning  incision.  The  first 
of  these  terms  was  formerly  employed  in  its  ordinary  and  vulgar 
sense  of  belly.  Since  operations  upon  the  stomach  proper  have  come 
into  vogue,  the  term  has  been  narrowed  in  its  significance,  and  is 
commonly  used  exclusively  to  designate  the  operation  of  making 
fistulse  into  that  organ. 

Laparotomy  (derived  from  Xairdpa,  the  flanks,  and  to/at;  [rifivuv,  to 
cut];  French,  laparotomie;  German,  Laparotomie)  was,  perhaps,  the 
next  coinage,  and  had,  originally,  a  meaning  that  was  entirely  consist- 
ent with  its  purpose.  It  was  employed  early  in  the  nineteenth  century 
to  designate  the  operations  in  the  inguinal  regions,  as,  for  instance,  for 
hernia  and  colotomy.  In  later  years,  however,  with  the  advent  of 
what  has  since  become  known  as  abdominal  surgery,  "  laparotomy  " 
was  made  to  mean  all  operations  upon  the  abdominal  wall.  This  was 
such  a  manifest  misapplication  of  the  original  meaning  of  the  term 
that  the  profession  has  largely  abandoned  its  use.  The  first  revolt 
was  emphasized  by  Lawson  Tait,  who  employed  in  its  stead  the 
expression  ''abdominal  section."  This  term,  in  turn,  has  occasioned 
considerable  discussion.  Greig  Smith  says  that  it  is,  perhaps,  "most 
objcctionaljlc    of    all;    an    abdoTtiinal    section,"    he    adds,    "is    made 

99 


100  A   TEXT-BOOK  OF   GYNECOLOaY 

on  a  frozen  cadaver  with  a  saw  for  anatomical  purposes;  it  is  not 
easy  to  understand  how  an  evil  chance  led  to  the  name  being 
given  to  an  incision  made  through  part  of  the  abdominal  wall  for  sur- 
gical purposes." 

This  criticism  must  be  recognised  as  of  doubtful  accuracy.  The 
word  "  section  "  is  derived  from  the  Latin  sectio,  meaning  simply  "  to 
cut."  A  statement  that  "  section  "  must  imj)ly  amputation  or  an  abso- 
lute severance  of  one  part  from  the  other,  is,  therefore,  an  unjustifiable 
stricture.  The  fact  remains  that,  by  convention  at  least,  it  has  come 
to  be  synonymous  with  incision.  This  has  been  verified  through  gen- 
erations, and  for  that  matter  centuries,  in  the  term  Csesarean  section. 
Latterly  we  hear  of  jjeriueal  section,  sagittal  section,  and  many  other 
equally  legitimate  applications  of  the  word.  The  word  coeliotomy — 
from  the  Greek  kolXm,  the  belly,  and  t€jxv€lv,  to  cut,  and  correspond- 
ing in  significance  with  the  French  cwliotomie,  the  G-erman  l-oilotomie 
and  hauchschnitt — does  not  materially  help  the  situation.  The  word  coe- 
liotomy was  brought  to  the  attention  of  the  profession  by  the  late 
Dr.  E.  P.  Harris,  of  Philadelphia,  although  Dr.  F.  P.  Foster,  writing 
on  the  subject,  says  "  this  term  seems  to  have  been  introduced 
by  Davies-Colley."  "  Some  good  people,"  continues  Foster,  "  write 
it  celiotomy;  many  consider  it  more  expressive  than  laparotomy,  but 
with  its  adoption  has  sprung  up  the  curious  term  '  abdominal  coe- 
liotomy,' an  abdominal  opening  of  the  abdomen,  as  distinguished 
from  vaginal  coeliotomy.  The  term  abdominal  section  answers  every 
purpose,  and  seems  to  me  ])referable  to  both  coeliotomy  and  lapa- 
rotomy." 

The  Preliminary  Treatment  of  the  Patient. — In  the  absence  of  an 
emergency,  such  as  hemorrhage,  acute  sepsis,  or  strangulation,  time 
should  be  taken  to  prepare  the  patient's  system  for  the  operation. 
This  should  be  done  by  giving  particular  attention  to  the  state  of  the 
secretions.  Most  patients,  particularly  those  of  the  more  chronic  class, 
are  constipated,  and  their  systems  are,  as  a  consequence,  laden  with  tox- 
ines  from  the  hyperabsorption  constantly  going  on  from  the  alimen- 
tary canal.  The  condition  is  all  the  more  serious  because  of  the  de- 
fective peristalsis  which  is  liable  to  be  still  further  weakened,  if  not 
entirely  arrested,  by  the  influence  of  the  operation  upon  the  sympa- 
thetic nervous  system.  It  is  highly  important,  therefore,  for  these 
two  reasons,  if  for  no  other,  that  the  bowels  should  be  not  only  un- 
loaded, but  brought  to  an  approximately  normal  standard  of  activity. 
This  is  best  done  by  giving  the  patient  a  small  dose  (one  sixtieth  of  a 
grain)  of  strychnine  with  salol  (three  grains)  three  times  daily  associ- 
ated with  a  persistent  course  of  salines.  For  the  latter  purpose 
the  magnesium  sulphate,  the  sodium  sulphate,  or  the  sodium  phos- 
phate, may  be  employed,  either  in  the  form  of  some  of  the  natural 
mineral  waters,  or  by  dissolving  some  of  the  salt  in  plain  water.  More 
important,  perhaps,  than  the  selection  of  the  remedy  is  the  manner  of 
its  administration.     The  best  results  are  obtained  by  giving  drachm 


ABDOMINAL  SECTION 


101 


doses,  beginning,  not  before,  but  after  a  meal.  If  the  chosen  remedy 
is  continued  in  this  way  during  twenty-four  hours  and  no  laxative 
effect  is  realized,  it  may  be  well  to  unload  the  bowels  of  their  now 
softened  contents  by  administering  one  full  dose  of  the  medicament, 
given  this  time  on  an  empty  stomach.  The  saline  should  not  be  dis- 
continued so  soon  as  the  bowels  have  been  evacuated,  although  a  little 
time  should  be  given  for  the  previously  secured  laxative  effect  to 
subside.  The  saline  should  then  be  resumed  in  half  doses,  given  an 
hour  or  two  after  each  meal.  In  this  way  it  becomes  mixed  with  the 
ingesta,  and,  by  stimulating  both  secretion  and  peristalsis,  prevents  a 
return  of  the  constipation.  A  constipation  of  long  standing  may 
thus  frequently  be  broken  up  in  the  course  of  a  week^  often  with 
permanent  results. 

The  Evil  of  Hy- 
percatharsis.  —  It  is 
highly  important  to 
urge  a  word  of  cau- 
tion against  the 
prevalent  habit  of 
purging  patients  ex- 
cessively before  op- 
erations. It  is  not 
unusual  for  patients 
to  be  forced  to  have 
a  dozen  or  more  de- 
jections during  the 
twelve  or  twenty- 
four  hours  before 
undergoing  the  or- 
deal of  an  abdominal 
section,  and  during 
this  time  they  are 
kept  upon  a  re- 
duced diet,  and  often 
during  the  final 
twelve  or  fifteen 
hours  are  given 
nothing  at  all  to 
eat.  It  should  be 
borne  in  mind  that 
such  hypercath  arsis 
(a)  weakens  the  pa- 
tient, (b)  still  further  weakens  peristalsis,  (c)  aggravates  post-operative 
thirst,  and  (d),  by  draining  the  circulation,  stimulates  all  of  the  absorb- 
ent functions,  and  thus  lays  the  foundation  for  systemic  sepsis  in 
the  presence  of  unavoidable  local  infection.  The  practice  is  wholly 
wrong  and  should  be  attandoned. 


Fig.  31. — "  Fenton  B.  Turck  covers  the  abdominal  wall  with 
a  sheet  of  rubber  dam." — Keed  (page  102). 


102  A  TEXT-BOOK   OP   GYNECOLOGY 

Examination  of  the  urine  is  very  important,  as  is  the  correction, 
by  judicious  medication,  of  an}^  error  tliat  may  be  found  in  that  secre- 
tion. The  condition  of  the  skin  should  equally  be  the  object  of  careful 
investigation  and  treatment.  This  latter  precaution  is  of  greater  impor- 
tance than  is  generally  recognised.  It  is  only  necessary  to  mention  that 
failure  of  the  urinary  function,  as  the  result  of  the  action  of  the  anaes- 
thetic on  the  kidneys,  is  one  of  the  most  frequent  fatal  complications 
following  visceral  operations;  and  that  in  the  presence  of  such  a  com- 
plication the  chief  hope  of  the  patient  lies  in  the  compensatory  activity 
of  the  sweat  glands.  It  is  highly  important,  therefore,  that  they  be 
piit  in  a  state  of  normal  activity  before  the  operation.  Baths,  if 
necessary,  with  dry  heat  or  steam  and  followed  by  friction,  continued 
during  several  days,  generally  constitute  all  the  treatment  that  is 
required. 

The  digestive  function  should  be  brought  to  as  high  a  state  of  effi- 
ciency as  possible. 

Fenton  B.  Turck  covers  the  abdominal  wall  with  a  sheet  of  rubber 
dam  (see  Fig.  31).  This  is  stretched  taut,  and,  being  translucent,  does 
not  obscure  the  underlying  integument;  the  incision  is  made  directly 


»y> 

■-^.^ 

/'— >-^^         . ■ — -^^^^^--—"'^             m 

He^^h 

,Jf„ 

C^— (5^^=^ 

pP^^R 

v" 

r— 

A;s===^ 

==sss^^ 

^--^^s-~^   '-"^JB 

^_/ 

^"•*****^         '''^**TBb 

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'. 

w^U^ 

Fig.  S2. — "  The  cut   edges  of  the   rubber  dam  are  brought  forward  and  tucked   into  the 

wound." — Reed. 

through  the  dam  just  as  if  it  were  a  part  of  the  skin.  After  the  inci- 
sion is  completed,  the  cut  edges  of  the  rubber  dam  are  drawn  for- 
ward and  are  tucked  into  the  wound,  covering  its  margins  and  being 
retained  by  a  clothes-pin  arrangement,  as  shown  in  the  drawing  (Fig, 
32).  The  rubber  dam  is  further  utilized  by  Turck  in  preventing  infec- 
tion of  the  peritoneal  cavity  by  drawing  a  loop  of  intestine  to  be  oper- 
ated upon  through  a  small  hole  in  the  rubber  sheet. 


ABDOMINAL   SECTION 


103 


Instruments  for  an  Abdominal  Section 


Aspirator. 

Cautery  (Paquelin). 

Forceps : 

Long  dressing 1 

Long  hemostatic 6 

Medium  liemostatic 3 

Small  hemostatic 3 

Bullet 1 

Rat-tooth 2 

Needles,  curved : 

Very  large  (No.  1) 1 

Large  (No.  4) 2 

Intermediate  (No.  3) 2 

Small  (No.  2) 2 

Intestinal  (No.  1) 2 

Transfixion,  right  curved 1 


Needles,  straight 2 

Needle  holder 1 

Retractors : 

Large 2  pairs 

Next  size  smaller  . .         2     " 

Scalpels 2 

Scissors : 

Long 1  pair 

Short 1     " 

Sound,  uterine 1 

Speculum,  Sims's  small 1 

Sponge  holders 4 

Tenaeula : 

Straight 1 

Curved 1 


Additional  Instruments  for   Ovarian   Cysts 
Trocars,  large  and  small.     Two  Nekton  forceps.     Rubber  tubing. 

Additional  Instruments  for  Extra-uierine  Pregnancy^  Hysteromyomectomy,  or 
Supravaginal  Hysterectomy^  and  Vaginal  or  Infravaginal  Hysterectomy 

One  dozen  pairs  of  long  hemostatic  forceps. 
Two  Museux's  forceps  for  seizing  tumours. 

Glassware 

Catheters 2 

Drainage  tubes,  assorted  sizes  : 

Straight 3 

Curved 3 

Flask,  sterilized,  to  receive  fluid  (contents  of  cysts,  etc.)  for  examination  1 

Nozzles  (for  irrigation) 2 


Preparation  of  the  Field  of  Operation. — (See  Preventive  Treatment 
of  Sepsis.) 

Location  of  the  Incision. — The  abdominal  incision  is  generally 
located  in  the  median  line  for  the  reason  that  this  particular  situation 
enables  the  operator  to  more  freely  handle  the  parts  of  the  abdominal 
and  pelvic  cavities.  This  rule  is  adopted  more  particularly  in  the  old 
operation  of  Cesarean  section,  and  in  the  more  recent  procedure  of  ova- 
riotomy. In  the  former  instance  it  was  manifestly  to  the  convenience  of 
the  operator  to  get  down  directly  upon  the  uterus.  In  the  second  class 
of  cases  it  was  more  desirable  because  it  enabled  the  surgeon  to  deal 
with  either  side  of  the  pelvis  with  equal  facility;  latterly,  however,  the 
principle  has  gained  recognition  that  the  incision  should  be  made 
directly  over  the  organ  or  structure  which  is  to  be  dealt  with. 


104: 


A   TEXT-BOOK  OF  GYNECOLOGY 


The  question  of  hernia  resulting  from  the  unsatisfactory  restora- 
tion of  the  incised  abdominal  wall  is  also  an  important  consideration  in 
determining  the  location  and  character  of  the  incision.  It  is  generally- 
supposed  that  the  cut  in  the  median  line  directly  through  the  linea  alba 
is  best  calculated  to  avoid  unpleasant  consequences.  Of  the  incision 
in  this  location,  it  may  be  said  that  it  is  the  easiest  to  make,  and,  by 
avoiding  blood  vessels,  is  least  complicated  with  hemorrhage.  It  is 
closed  with  great  facility,  and  the  union  which  ensues  is  generally  very 
satisfactory.  If  infection  should  occur,  however,  the  approximation 
of  the  structures,  however  accurately  made,  may  be  destroyed,  and  the 
margin  of  the  wound  thus  become  retracted.  This  is  of  very  serious 
import  when  the  incision  is  a  little  to  one  side  or  the  other  of  the 
median  line,  and  when  the  separation  involves  the  margins  of  the 
fasciae.  This — i.  e.,  separation  of  the  fascia — -is  the  underlying  condi- 
tion of  post-operative  ventral  hernia;  to  avoid  this  accident  many  oper- 
ators prefer  to  invade  the  abdominal  cavity  a  little  to  one  side  or  the 
other  of  the  median  line,  some  preferring  to  go  as  far  to  one  side  as  the 

outer  margin  of  the 
rectus  muscle;  some 
preferring  to  go  di- 
rectly through  the 
rectus  ;  while  still 
others  open  the 
sheath  of  that  muscle 
near  the  median  line, 
pushing  the  muscle 
itself  to  one  side  and 
continuing  the  inci- 
sion through  the 
middle  of  the  under- 
lying layer  of  sheath 
and  fascia.  In  this 
way  it  is  contended 
that  should  one  layer 
separate,  the  other 
layer,  directly  super- 
imposed, will  exercise 
a  greater  retentive 
power,  and  thus  pre- 
vent the  development 
of  hernia. 

This   principle    is 

one  which  is  capable 

of  adoption  in  many 

operations.    It  should  be  observed,  especially  in  fat  subjects,  where,  in 

consequence  of  the  disuse  of  the  abdominal  muscles,  or  of  the  stretching 

incident  to  distention  by  fat.  Or  from  the  pressure  due  to  the  presence 


Fig.  33. — "  The  incision  may  be  made  in  that  locality  which 
will  afford  the  greatest  facility  in  dealing  with  the  under- 
lying internal  conditions."— Reed  (page  105). 


ABDOMINAL   SECTION  105 

of  deposits  of  adipose  tissue,  the  structures  of  the  abdominal  wall  are 
materially  weakened.  It  should  be  remembered  that  an  incision  may 
be  made  at  any  point  in  the  abdominal  wall,  and  that  there  are  no 
blood  vessels  contained  therein  the  hemorrhage  from  which  is  not 
readily  controllable.  As  a  rule,  therefore,  the  incision  may  be  made 
in  that  locality  which  will  afford  the  surgeon  the  greatest  facility  in 
dealing  with  the  underlying  internal  conditions  (Fig.  33). 

Direction  and  Varieties  of  Incision. — While  the  foregoing  is  true,  it 
is  also  true  that  there  are  distinct  advantages  to  be  gained  by  definitely 
and  accurately  arranging  the  direction  of  the  incision  into  and  through 
the  abdominal  wall.  It  is  also  true  that,  consistently  with  the  object  in 
view,  the  incision  is  best  made  (a)  coincidently  with  the  cutaneous 
folds,  and  (5)  coincidently  with  the  muscular  fibres  and  fascial  striw. 
This  principle  was  enunciated  by  Kocher  (Operative  Surgery,  New 
York,  1894),  who  definitely  outlines  the  incisions  to  be  made  for  vari- 
ous purposes,  some  of  which  come  properly  within  the  range  of  a  work 
on  gynecology,  and  are  given  herewith.  The  line  of  the  median  ab- 
dominal incision  is,  as  already  stated,  the  one  most  commonly  employed. 
While  it  is  made  transversely  to  the  normal  cutaneous  folds  it  is  coin- 
cident with  the  recti  muscles,  a  fact  that  conduces  largely  to  the  easy 
and  permanent  approximation  of  the  deeper  structures.  The  results,  so 
far  as  the  skin  is  concerned,  are,  however,  often  somewhat  unfortu- 
nate, if  from  no  other  than  an  sesthetic  point  of  view.  The  retraction 
of  the  skin  that  frequently  ensues,  notwithstanding  the  most  careful 
approximation  of  the  cutaneous  margins,  frequently  results  in  post- 
operative widening  of  the  cicatricial  area.  Frequently  under  this  in- 
fluence the  scar  tissue  undergoes  what  is  spoken  of  as  a  keloid  change. 
When,  therefore,  the  cutaneous  incision  can  be  made  transversely, 
the  underlying  layers  being  divided  in  any  direction  to  suit  the  oper- 
ator, but  preferably  in  the  direction  of  their  respective  stricB,  the  result 
is  always  more  satisfactory.  There  is  nothing  more  striking  than  the 
difference  between  a  scar  made  transversely  to,  and  one  coincidently 
with  the  cutaneous  folds,  the  latter  becoming  practically  imperceptible 
after  a  very  few  weeks,  while  the  former  shows  a  constant  tendency  to 
increase  in  size  and  to  diminish  in  retentive  power. 

The  Vertical  Median  Incision. — The  incision  E  (Fig.  33)  may  be 
called  the  low  vertical  median  incision,  while  that  designated  G 
(Fig.  33)  is  the  high  vertical  median  incision.  The  latter  should  be 
employed  in  operations  upon  the  stomach,  and  in  other  operations  in 
which  it  is  desirable  to  reach  the  organs  lying  in  the  upper  part  of 
either  of  the  upper  quadrants  of  the  abdominal  cavity.  A  vertical  in- 
cision (//,  Fig.  33)  is  sometimes  made  in  the  left  upper  quadrant  for 
operations  upon  the  spleen.  The  incision  in  the  median  abdominal 
line  is  the  best  in  all  cases  in  which  it  is  necessary  to  deal  with  both 
siflos  of  the  pelvis,  or  in  those  cases  in  which  it  may  be  uncertain  as  to 
which  sifl(;  of  the  pelvis  may  be  the  ultimate  seat  of  operation.  The 
median  line  is,  as  a  riih-,  1lic  safer  locus  for  a  genei-al  exploratory  in- 


106  A   TEXT-BOOK  OF   GYNECOLOGY 

cision.  It  should  always  be  employed  in  the  presence  of  surgical  condi- 
tions lying  immediately  beneath  it. 

The  Transverse  Umbilical  Incision. — This  incision  is  made  trans- 
versely at  the  umbilicus,  and  may  be  employed  in  dealing  with  prac- 
tically all  conditions  developing  in  that  locality.  It  is  the  ideal  in- 
cision in  the  management  of  umbilical  hernia.  As  a  rule,  a  post- 
operative ventral  hernia,  occurring  in  this  locality,  or,  for  that  matter, 
at  any  other  point  above  or  below  the  umbilicus,  may  be  safely  and 
desirably  approached  through  a  transverse  incision,  while  the  her- 
nia itself  should  be  approximated  in  a  transverse  rather  than  a  longi- 
tudinal line.  This  line  of  incision  is  of  especial  importance  in  fat 
people.  These  patients,  lying  upon  their  backs,  exercise  all  of  the 
gravity  which  is  derived  from  the  heavy  and  mobile  abdominal  walls  in 
a  spontaneous  tendency  to  retract  from  the  longitudinal  median  line, 
while  their  equally  natural  tendency  is  to  hold  a  transverse  ajDproxi- 
mation  in  continued  apposition. 

The  Transverse  Suprapubic  Incisio7i  (C,  Fig.  33). — This  incision 
should  be  made  transversely  to  the  median  line,  immediately  above 
the  pubes,  in  all  operations  in  which  it  is  desirable  to  approach  the 
bladder  from  the  outside.  This  occurs  with  frequency  in  gynecological 
practice. 

The  Oblique  Ventral  Incision  (A,  Fig.  33). — The  oblique  ventral  in- 
cision should  be  employed  in  dealing  with  the  common  iliac  artery,  as 
sometimes  becomes  necessary  in  gynecological  practice;  it  may  be  used 
on  the  right  side  in  dealing  with  the  suppurations  about  the  head  of  the 
colon  and  in  appendicitis,  or  in  surgical  conditions  pertaining  to  the 
pelvic  bones  on  that  side.  On  the  left  side  it  is  the  avenue  of  approach 
to  the  sigmoid  flexure  as  well  as  to  the  common  iliac  artery. 

The  Inguinal  Incision  (B,  D,  Fig.  33). — The  inguinal  incision  may 
be  made  either  above  or  below,  but  coincidently  with,  the  line  of  Pou- 
part's  ligament.  In  the  former  position  it  may  be  employed  in  inguinal 
hernia  or  to  reach  conditions  beneath  the  broad  ligament  in  order  that 
they  may  be  dealt  with  without  communicating  with  the  peritoneal 
cavity.  Suppuration  in  this  locality  may  be  evacuated  and  drained  by 
an  incision  along  this  line,  while  retroperitoneal  myotomy,  or,  for  that 
matter,  intraligamentary  cysts,  may  be  approached  by  this  incision, 
after  their  true  character  has  once  been  determined  by  the  incision  in 
the  median  line. 

This  incision  is  sometimes  made  below  Poupart's  ligament  in  deal- 
ing with  femoral  hernia  and  with  conditions  connected  with  the  fem- 
oral artery. 

The  Oblique  Subcostal  Incision  (F,  Fig.  33). — The  oblique  subcostal 
incision  should  be  made  from  a  half  to  three  quarters  of  an  inch  be- 
neath the  costal  margins,  extending  from  the  outer  margin  of  the  rectus 
muscles  to  as  far  around  the  side  as  may  be  necessary.  This  operation 
is  sometimes  desirable  in  making  explorations  for  the  kidney — a  pro- 
cedure which  comes  within  the  purview  of  this  work;  it  is  usually  em- 


ABDOMINAL  SECTION  lOY 

ployed,  however,  for  operations  upon  the  gall  bladder,  which  are  not 
considered  in  this  volume. 

The  Lumho-iliac  Incision. — This  incision  begins  near  the  last  costo- 
vertebral articulation,  extending  downward  and  forward  in  the  direc- 
tion of  the  crest  of  the  ilium.  It  may  be  employed  in  the  case  of  ne- 
phrectomy, or  for  the  complete  removal  of  the  ureter. 

The  Lumbocostal  Incision. — This  incision  is  made  from  a  point 
one  to  two  inches  to  the  side  of  the  posterior  median  line,  and  carried 
obliquely  downward,  forward,  and  upward  below  the  costal  margin. 
It  is  employed  for  operations  upon  the  kidney. 

General  Observations  on  making  the  Incision. — ^Wherever  the  inci- 
sion may  be  located  it  should  be  made  deliberately,  all  attempts  at 
haste  being  avoided.  The  layers  should  be  incised  one  by  one.  Bleed- 
ing points  will,  of  course,  be  encountered,  some  localities  and  some 
patients  being  more  vascular  than  others.  The  blood  should  be  speed- 
ily wiped  away  by  means  of  a  bit  of  dry  sterilized  gauze,  so  that  the 
structures  may  be  kept  clearly  in  view.  The  gauze  thus  used  should  be 
immediately  thrown  away.  M^ich  time  is  often  lost  in  needless  atten- 
tion to  unimportant  bleeding.  As  a  rule,  that  bleeding  which  is  merely 
capillary  or  venous  may  be  left  to  itself,  while  a  i3ulsating  jet  should  be 
at  once  controlled  by  means  of  a  hemostatic  forceps.  This  should 
not  be  hastily  applied,  and  should  always  be  adjusted  with  care  and 
precision.    Many  careless  operators  and  assistants  simply  take  a  large 


Fig.  34. — "  The  presenting  structure  should  be  picked  up  by  two  hemostatic  forceps." — Keed. 

bite  of  ti.ssue  somewhere  in  tlie  noiglibourliood  of  the  bleeding  point, 
with  the  object,  of  course,  of  controlling  the  hemorrhage.  The  pres- 
sure thus  imposed  upon  the  tissue,  particularly  the  adipose  tissue,  which 
is  found  in  such  abundance  in  the  abdominal  wall,  is  liable  to  induce 


108 


A  TEXT-BOOK  OP  GYNECOLOGY 


necrosis,  and  thus  interfere  with  primary  union.  A  few  seconds  of  time 
should  he  taken  to  isolate  more  or  less  definitely  the  hleeding  point, 
which  should  then  be  picked  up  accurately  by  the  point  of  the  hemo- 
static forceps. 

As  soon  as  the  deej)  fascia  or  the  subperitoneal  fat  is  reached,  the 
presenting  structure  should  be  picked  up  by  two  hemostatic  forceps  (Fig. 

34),  which  should  be  re- 
applied as  often  as  may 
be  necessary  to  hold  the 
peritoneum  away  from 
the  underlying  viscera. 
The  moment  the  peri- 
toneum is  nicked  the 
air  rushes  in  and  the  in- 
testines fall  away  from 
the  abdominal  wall. 
Failure  to  observe  this 
precaution  sometimes  re- 
sults in  the  totally  un- 
necessary wounding  of 
the  intestines  or  other 
structures  within  the  ab- 
dominal cavity.  The 
peritoneum  should  be 
carefully  incised  by 
means  of  either  scissors 
or  a  knife,  coincidently 
and  coextensively  with 
the  upper  part  of  the  in- 
cision (Fig.  35). 

As  soon  as  the  peri- 
toneum is  opened,  care 
should  be  taken  to  per- 
manently arrest  all  hem- 
orrhage in  the  abdominal 
incision  and  to  remove 
the  forceps.  In  the  course 
of  an  operation  it  may  be, 
and  frequently  is,  neces- 
sary to  enlarge  the  inci- 
sion; in  doing  so  great  care  should  be  exercised  to  make  the  additional 
opening  directly  in  line  with  the  previous  one,  and  to  observe  the 
same  precautions  in  dealing  Avith  the  incidental  hemorrhage.  It  is 
better  to  employ  a  knife  for  this  purpose  rather  than  the  scissors,  which 
are  generally  so  convenient,  so  expedient,  and  so  generally  utilized  by 
the  hurried  surgeon.  The  scissors  are  objectionable,  because  in  the  act 
of  cutting  they  produce  a  certain  amount  of  cell  destruction,  which  is 


Fig.  35. — "The  i>fi'itiiiiciiiu  should  be  carefully  incised 
.  .  .  coincidently  and  coextensively  with  the  upper 
part  of  the  incision." — Reed. 


ABDOMINAL  SECTION 


109 


obviated  by  the  keener  edge  of  the  knife.  The  incision  having  been 
made  as  large  as  necessary,  the  operation,  whatever  it  may  be,  is  car- 
ried to  completion. 

The  Closure  of  an  Abdominal  Incision. — There  are  various  methods 
of  closing  the  abdominal  incision.  The  question  of  interrupted  or  con- 
tinuous suture,  the  question  of  suture  material,  and  the  question  of 
sealing  or  not  sealing  the  wound,  are  all  to  be  considered;  this  is  bet- 
ter done  with  reference  to  the  necessity  or  not  of  maintaining  drainage. 

The  Immediate  and  Complete  Closure  of  an  Abdominal  Incision. — 
When  the  operation  has  been  successfully  concluded,  when  the  field 
of  operation  has  remained  free  from  infection,  when  hemostasis  has 
been  secured,  and  when  there  are  no  remaining  doubts  as  to  the  safety 
of  the  internal  conditions,  the  abdominal  wound  may  be  closed  com- 
pletely and  at  once  by  one  of  the  following  methods : 

Closure  by  the  Laminated  Suture. — The  ideal  method  of  closure  is 
by  the  approximation,  edge  to  edge,  of  like  structures;  thus  the  peri- 
toneum to  the  peritoneum,  the  tranversalis  fascia  to  the  transversalis 
fascia,  the  superficial  fascia  to  the  superficial  fascia,  and  the  integu- 
ment to  the  integument,  should  be  successively  approximated.  This 
may  be  done  either  by  continuous  or  interrupted  suture  or  chromicized 
or  formalinized  catgut.  The  kangaroo  tendon  and  other  tendinous 
materials  have  a  certain  vogue  for  this  purpose,  but  they  are  not  essen- 
tial to  success.  If  a  continuous  suture  is  applied  in  each  layer  it  ought 
to  be  supplemented  by  a  number  of  interrupted  sutures  in  the  fascial 
layers,  as  these  structures  are  more  prone  to  retract  than  are  the  others, 
and  they  are  likewise 
the  chief  retentive  tis-  5"  "^^ 
sues  of  the  abdominal 
wall.  It  is  not  safe, 
therefore,  to  trust  their 
approximation  to  a  sin- 
gle continuous  suture. 
The  application  of  the 
sutures  to  the  various 
layers  is  largely  facili- 
tated by  drawing  up,  by 
two  small  volsella  for- 
ceps, each  consecutive 
layer  into  the  field  of 
operation  (Fig-  36). 
Volsella  forceps  are 
vastly  better  adapted  to 
this  ymrpose  than  are 
those  used  for  hemo- 
stasis, because  they  exercise  no  pi-essure,  and  consequently  induce  no 
cell  destruction.  The  skin  should  be  closed  by  means  of  intercuta- 
neous  suture,  1jiit  before  starting  this  suture  the  end  should  be  fastened 


Fig.  36. — "  The  application  of  the  sutures  to  the  various 
layers  is  largely  facilitated  by  drawing  up,  by  small 
volsella  forceps,  each  consecutive  layer  into  the  field 
of  operation." — Keed. 


110 


A  TEXT-BOOK  OF   GYNECOLOGY 


in  such  a  way  as  to  place  the  knot  deep  in  the  subcutaneous  fat  (Fig.  37) 
in  order  that  its  absorption  may  be  insured.  This  is  done  by  passing 
the  needle  through  the  subcutaneous  fat  from  beneath,  carrying  it 
across  to  the  other  margin  of  the  wound,  and  downward  through  the 
fat,  bringing  it  out  at  a  point  corresponding  to  the  original  insertion 

on  the  other  side.  The  suture  is 
now  tied  and  the  short  end  cut 
close.  In  order  to  secure  perfect 
approximation  at  the  end  of  the 
wound,  the  first  intercutaneous 
suture  is  passed  toward  the  end 
from  which  the  suture  starts 
(Fig.  38).  The  remaining  su- 
tures   are    passed    in    the    other 


Fig.  37. — "The  end  should  be  fastened  in 
such  a  way  as  to  place  the  knot  deep  in 
the  subcutaneous  fat." — Eeed. 


Fig.  38. — "  The  first  intercutaneous  su- 
ture is  passed  toward  the  end  fi'om 
which  the  suture  starts." — Eeed. 


direction,  the  margins  of  the  skin  being  carefully  drawn  together 
(Fig.  39).  There  are  connected  with  this  last  manoeuvre  certain  dan- 
gers, for  instance,  the  unsuccessful  application  of  the  sutures,  leaving  a 
gaping  point  to  serve  as  an  infection  atrium;  or,  on  the  other  hand,  if 
too  tightly  drawn  after  they  have  been  inserted,  the  pressure  itself 
may  be  destructive  of  the  integument  and  may  result  in  a  necrosis, 
which  is  disastrous  to  primary  union.  After  having  applied  the  inter- 
cutaneous suture  there  may  be  some  retraction  of  the  subcutaneous  fat, 
a  condition  which  is  easily  remedied  (Fig.  40).  This  is  done  by  taking 
a  long  curved  needle,  inserting  it  an  inch  or  less  back  from  the  line  of 
incision,  crossing  the  incision  itself,  and  bringing  the  needle  out  at  a 
corresponding  distance  on  the  other  side.     The  needle  is  then  rein- 


ABDOMINAL  SECTION 


111 


serted  through  the  aperture  of  exit,  and  is  carried  in  a  more  or  less 
oblique  way  back  to  the  opposite  side,  where  it  is  brought  out  half  an 
inch  distant  from  the  point  of  original 
insertion  (Fig.  41).  The  suture  thus 
buried  approximates  the  underlying 
fat,  and  in  an  important  degree  forti- 
fies the  cutaneous  approximation.  It 
is  returned  in  the  same  manner  until 
the  whole  line  of  incision  has  been 
brought  under  the  influence  of  the 
suture.  It  is  then  tied  under  the  skin 
by  inserting  the  needle  and  working 
its  point  two  or  three  times  around 
the  strand  of  catgut  immediately  un- 
der the  skin.  The  needle  is  then 
brought  out  on  the  other  side  and  the 
catgut  excised  under  traction  close  to 
the  skin.  The  end  immediately  re- 
tracts and  the  whole  operation  will 
have  been  completed  entirely  beneath 
the  integument. 

It  is  well  in  the  majority  of 
cases  to  seal  the  wound  by  adjusting 
over  it  a  little  sterilized  gauze  fixed 
to  the  surface  by  means  of  collodion, 
but  the  impossibility  of  sterilizing  col- 
lodion should  prevent  its  application 
directly  to  the  margins  of  the  wound. 
After  the  abdomen  is  well  cleansed 
and  dried  it  should  be  tightly  bound 
with  a  cloth  bandage.  That  in  use 
at  the  Cincinnati  Hospital  is  probably 

more  advantageous  than  others,  it  being  held  firmly  in  place  by  two 
flaplike  elongations  of  the  back  part  which  are  brought  up  between  the 

thighs  and  fastened  to 
the  front  of  the  bandage 
(Fig.  42). 

Closure  where  Drain- 
age is  Necessary.  —  In 
many  operations  it  is  not 
possible  to  secure  com- 
plete hemostasis  or  that 
degree  of  asepsis  com- 
patible with  safety,  or  to 
control  other  surgical  conditions  to  a  degree  that  will  justify  the  com- 
plete closure  of  the  abdominal  incision.  Drainage  must,  therefore,  be 
employed  and  an  orifice  of  exit  must  be  provided.     This  is  sometimes 


Fig.  39.— "The  remaining  sutures  are 
passed  iu  the  other  direction,  the 
margins  of  the  skin  being  carefully 
drawn  together." — Eeed  (page  110). 


Fig.  40. — "  After  having  applied  the  intercutaneous  su- 
ture there  may  be  some  retraction  of  the  subcutaneous 
fat,  a  condition  which  is  easily  remedied." — Reed 
(page  110). 


112 


A   TEXT-BOOK   OF   GYNECOLOGY 


Fig.  41. — "  The  needle  is  reinserted  through  the  aperture  of 
exit,  and  is  carried  in  a  more  or  less  oblique  way  back  to 
the  opposite  side." — Reed  (page  111). 


done  by  making  an 
opening  in  the  cul-de- 
sac  of  Douglas  and 
carrying  a  self -retain- 
ing tube  out  through 
the  vagina.  In  other 
instances  this  will  not 
suffice.  Many  opera- 
tors still  cling  to  the 
old  glass  tube  and 
pump,  while  in  certain 
other  instances  it  is 
necessary  to  pack  the 
field  of  operation  with 
gauze  and  bring  one  end  of  it  out  through  the  incision.  The  neces- 
sity for  the  latter  expedient  is  sometimes  so  great  as  to  make  it  neces- 
sary to  leave  open  the  entire  wound.  Under  any  of  these  circumstances 
it  is  necessary  to  leave  a  part  or  all  of  the  incision  open.  In  such 
cases  it  is  not  better  to 
employ  the  buried  animal 
suture,  for  the  reason 
that  the  drainage,  how- 
ever established  or  how- 
ever maintained,  is  neces- 
sarily a  fruitful  source  of 
infection;  and  infection 
once  communicated  to 
the  continuous  laminated 
animal  suture  is  liable  to 
invade  all  of  the  struc- 
tures that  may  be  approx- 
imated by  it. 

Closure  hy  the  Suture 
En  Masse. — To  close  the 
wound  when  drainage  is 
required,  the  suture  en 
masse  should  be  em- 
ployed. This  may  con- 
sist of  silk,  silver  wire 
or  silkworm  gut — the  lat- 
ter on  all  accounts  being 
preferable.  The  material, 
having  been  sterilized,  of 
course,  may  be  inserted 
from  the  skin  to  the  peri- 
toneum, carried  across 
from  peritoneum  to  ]3eri- 


FiG.  42. — "  The  bandage  in  use  at  the  Cincinnati  Hos- 
pital is  probably  more  advantageous  than  others." — 
Eeed  (page  111). 


ABDOMINAL  SECTION 


113 


Fig.  43.— The  needle  devised  by  Dr.  J.  B.  S. 
Holmes. — Reed. 


toneum  and  through  from  peritoneum  to  skin.  For  this  purpose  many 
operators  prefer  a  straight  needle;,  others  a  curved  one;  the  most  satis- 
factory one  which  the  writer  has  encountered  has  been  devised  by  Dr. 
J.  B.  S.  Holmes,  of  Atlanta,  Ga.  It  is  a  round  needle  bent  at  an 
angle  near  the  point,  which  has  a  bayonet  finish  (Fig.  43).  The  needle 
in  passing  through  the  ab- 
dominal wall  should  be 
made  to  define  an  arc  of  a 
•circle,  so  that  when  drawn 
together  the  intermediate 
structures  will  be  brought 

well  forward  and  forced  into  approximation  (Fig.  44).  In  a  few  in- 
stances it  may  be  found  necessary  to  bring  the  traction  to  bear  more 
specifically  upon  the  margins  of  the  fascia.  This  is  accomplished  by 
■a,  figure-of-eight  arrangement,  effected  as  follows:  The  needle  is  in- 
serted through  the  skin  and  superficial  fascia,  brought  out  into  the 

margin  of  the  wound, 
inserted  into  the  oppo- 
site side  just  below  the 
superficial  fascia,  car- 
ried through  the  peri- 
toneum, crossed  over, 
inserted  through  the 
peritoneum  and  brought 
out  just  beneath  the  su- 
perficial fascia,  crossed 
over  to  the  other  side, 
inserted  through  the  superficial  fascia,  and  brought  out  through  the 
skin.  The  resulting  suture  is  a  complete  figure  eight,  which  forces 
into  approximation  the  fascia  which,  under  many  circumstances,  is 
prone  to  retract  to  a  degree  calculated  to  defeat  the  union  (Fig.  45). 
The  sutures  having  been  inserted,  the  ends  are  gathered  together 
upon  either  side  and 
the  entire  abdomi- 
nal wall  is  drawn 
away  from  the  in- 
testines, the  perito- 
neal margins  being 
forced  together  by 
properly  directed 
traction  upon  all 
the   sutures.      This 

having  been  done,  the  ends  of  the  sutures  may  be  permitted  to  lie  freely 
while  the  operator  ties  each  one  seriatim.  If  the  material  is  silkworm 
gut  the  preliminary  loop  of  the  knot  should  be  accomplished  by  three 
turns,  and  sliouhl  be,  drawn  tog(3tlicr  with  just  sufficient  force  to  effect 
the  approxiiiiaiion  of  the  tissues,  but  without  force  enough  to  interfere 
9 


Fig.  4A. — "  The  needle,  in  passing  through  the  abdominal 
wall,  should  be  made  to  define  the  arc  of  a  circle." — 
Eeed. 


Fig.  45. — "The  resulting  suture  is  a  complete  figure  of 
eight." — Reed. 


114  A  TEXT-BOOK   OF   GYNECOLOGY 

Avitli  the  local  nutrition  of  the  parts.  A  suture  that  blanches  the  skin 
under  it  is  tied  too  tightly.  This  can  not  always  be  avoided,  because 
the  post-operative  engorgement  of  the  parts  sometimes  increases  pres- 
sure to  a  dangerous  degree.  If  the  suture  has  been  secured  as  already 
indicated — namely,  by  an  extra  whirl  in  the  preliminary  loop — it  is 
totally  unnecessary  to  •  ajsply  the  usual  second  loop  for  fixation.  If, 
then,  the  tension  should  subsequently  appear  to  be  too  great,  the  suture 
can  be  loosened.  An  extra  suture  may  be  inserted  to  secure  approxima- 
tion at  the  point  occupied  for  drainage.  If  applied,  this  suture  should 
be  left  loose  until  after  the  drainage  is  concluded.  It  may  be  stated,  as- 
a  rule,  however,  that  this  expedient  is  one  of  doubtful  utility,  and  is 
not  infrequently  fraught  with  some  danger.  It  is  better,  as  a  rule,, 
to  leave  that  section  of  the  wound  which  has  been  employed  for  drain- 
age open  for  spontaneous  closure. 

Drainage. — Drainage  was  at  one  time  considered  more  essential  tO' 
success  in  abdominal  surgery  than  it  is  at  the  present  day.  At  the  time 
when  surgeons  were  less  sure  of  hemostasis  it  was  a  safeguard  in  detect- 
ing internal  hemorrhage,  and  it  should  yet  be  employed  in  all  cases  in 
which  the  operator  has  any  doubt  about  having  controlled  the  bleed- 
ing. In  former  times,  when  the  toilet  of  the  peritoneum  was  less  care- 
fully made  than  at  present,  drainage  was  essential  for  the  escape  of 
pus,  which  continued  to  form  until  limited  by  the  self-extermination 
of  its  micro-organisms.  Drainage  may  be  practised  by  leaving  in  the 
abdominal  wound  a  glass  tube  extending  to  the  bottom  of  the  pelvis.. 
Through  this  tube  the  accumulated  fluids  are  sucked  with  an  appa- 
ratus consisting  of  either  a  syringe  or  a  rubber  bulb  with  a  glass  barrel 
attached  to  a  bit  of  rubber  tubing.  The  manipulation  requires  great 
care  to  prevent  infection,  the  liability  to  which  by  this  means  consti- 
tutes one  of  the  chief  objections  to  drainage  as  a  routine  measure.  In 
many  abdominal  operations  in  which  it  is  desirable  to  promote  the 
escape  of  fluid,  drainage  is  effected  by  making  an  opening  in  the  floor 
of  the  cul-de-sac  of  Douglas  and  inserting  through  that  into  the  vagina 
either  a  small  rope  of  gauze,  or  preferably  a  T-drainage  tube.  These 
are  made  of  rubber  after  the  pattern  of  Martin,  but  as  found  in  the 
shops  are  unnecessarily  expensive.  Just  as  efficient  a  drainage  tube 
can  be  made  by  taking  a  piece  of  ordinary  quarter-inch  drainage 
tubing,  eight  inches  long,  and  cutting  it  off  oval  at  one  end.  The  tube 
is  then  split  for  a  distance  of  an  inch  and  a  half  into  two  flaps;  an  eighth 
of  an  inch  below  the  base  of  each  flap  a  small  hole  is  cut  into  each 
side  of  the  tube;  through  each  of  these  holes  the  corresponding  flap 
is  drawn  by  means  of  an  ordinary  hemostatic  forceps;  the  result  is  the 
formation  of  a  T-tube  of  great  utility  (Fig.  46).  Delageniere  has  de- 
vised metal  drainage  tubes,  but  their  advantages  are  not  obvious.  G-auze 
has  been  used  for  drainage  purposes,  but  it  speedily  becomes  filled  with 
the  secretions,  which  it  fails  to  conduct  out  of  the  cavity;  its  use,  there- 
fore, should  be  limited  to  those  cases  in  which  the  fluid  expected  to  be 
taken  out  by  it  is  not  in  excess  of  the  absorbing  capacity  of  the  gauze  tO' 


ABDOMINAL  SECTION 


111 


be  used.  J.  Gr.  Clark  investigated  the  general  question  of  drainage  in 
seventeen  hundred  abdominal  sections  at  the  Johns  Hopkins  Hos- 
pital {American  Journal  of  Obstetrics,  April,  1897).  In  approaching 
his  investigations  he  proceeded  upon  the  conclusions  of  Muscatello — 


Fig.  46. — "  The  result  is  the  formation  of  a  T-tube  of  great  utility.'' — Eeed  (page  114). 


viz.:  (1)  the  surface  of  the  peritoneum  is  equivalent  to  that  of  the  skin; 
(2)  it  has  an  enormous  absorbing  function,  taking  up  in  an  hour  from 
3  to  8  per  cent  of  the  entire  body  weight;  (3)  under  the  influence 
of  very  toxic  or  very  irritant  substances  an  equal  transudation  into 
the  peritoneal  cavity  may  take  place.  Clark,  from  a  general  study 
of  the  subject  as  well  as  from  these  investigations,  concludes  that — 

1.  Fluids  and  solids  may  pass  through  the  endothelial  layer  of  the 
peritoneum,  the  fluids  in  many  places,  the  solid  particles  only  through 
the  spaces  in  the  diaphragm. 

2.  The  minute  solid  particles  are  carried  into  the  mediastinal  lymph 
vessels  and  glands,  and  thence  into  the  blood  circulation,  by  which 
they  are  distributed  to  the  abdominal  organs  and  lymph  glands. 

3.  Large  quantities  of  fluids  may  be  absorbed  by  the  peritoneum  in 
an  astonishingly  short  time. 

4.  The  leucocytes  are  largely  the  bearers  of  foreign  bodies  from  the 
peritoneal  cavity  into  the  mediastinal  lymph  glands. 

As  the  result  of  the  experimental  study  of  infection  of  the  perito- 
neum by  Grawitz,  it  has  been  shown  that — 

1.  The  introduction  of  nonpyogenic  organi.sms  into  the  abdom- 
inal cavity,  either  in  small  or  large  quantity,  or  mixed  with  formed  par- 
ticles, produces  no  harm. 

2.  Great  quantities  of  organisms,  which  ordinarily  produce  no  dis- 
turbance, may  give  rise  to  a  general  asepsis  if  the  absorptive  ability  of 
the  peritoneum  is  impaired. 

3.  '^rhe  injection  of  pyogenic  organisms  into  tlie  peritoneal  cavity 
may  be  quite  as  harmless  as  injection  of  the  nonpathogenic  varieties. 


116  A  TEXT-BOOK  OF  GYNECOLOGY 

4.  The  introduction  of  pus-producing  cocci  causes  a  purulent 
peritonitis  (a)  if  the  culture  fluid  is  difficult  of  absorption;  (b)  if  there 
is  present  irritating  material  which  destroys  the  tissues  of  the  perito- 
neum, and  thus  prepares  a  |)lace  for  the  lodgment  of  organisms;  (c)  if 
a  wound  of  the  abdominal  wall  is  present  which  forms  a  nidus  for  the 
infectious  process.  In  this  latter  case  purulent  peritonitis  will  cer- 
tainly be  produced. 

It  was  further  found  that  the  area  drained  by  a  tube  speedily  be- 
came limited,  almost  to  the  circumference  of  the  tube  itself;  that  the 
tube  frequently  acted  mechanically,  and  thus  perpetuated  the  peritoneal 
exudation;  that  the  serum  throAvn  off  by  the  peritoneum  acted  as  the 
best  possible  culture  medium  for  germs  introduced  from  without;  and, 
finally,  that  any  agents  that  had  any  possible  effect  upon  bacteria  acted 
as  an  irritant  to  the  peritoneum,  and  thus  defeated  the  purpose  for 
which  they  were  employed. 


CHAPTER    XIII 

THE   EXTERNAL  ORGANS  OF   GENERATION   IN  WOMEN 

Names  and  definitions — Development — The  vulva  and  its  malformations:  atresia; 
infantile ;  double ;  persistent  cloaca ;  persistent  urogenital  sinus ;  epispadias  in 
women;  precocious  development;  individual  malformations  of  the  labia,  cli- 
toris, and  perineum;  pseudo-hermaphroditism:  (a)  masculine,  (b)  feminine — 
The  vagina  and  its  malformations :  absence ;  atresia ;  stenosis ;  double  or  sep- 
tate— The  hymen  and  its  malformations :  atresia ;  double ;  absence ;  anomalies 
in  (a)  form,  (1))  structure,  (c)  anterior  extension. 

The  external  organs  of  generation  in  women  consist  of  the  puden- 
dum and  vagina.  The  pudendum  embraces  the  structures  known  as 
the  mons  veneris,  the  labia  majora,  the  labia  minora,  the  clitoris  and 
prepuce,  the  vestibule  and  fourchette,  and  the  hymen.  The  word 
"  vulva  "  applies  to  all  of  these  •external  structures  excejat  the  mons 
veneris.  For  convenience  of  classification  the  perineum  will  be  con- 
sidered in  this  same  group. 

Development  of  the  Genital  Organs. — The  genital  organs,  whether 
male  or  female,  have  their  embryologic  origin  in  the  Wolffian  body, 
Mliller's  ducts,  and  the  genital  glands.  From  the  Wolffian  body,  or  the 
primordial  kidney,  there  appear  on  the  inner  portion,  and  in  the  fifth 
and  sixth  months  of  utero-gestation,  the  genital  glands,  which  subse- 
quently evolve  into  either  ovaries  or  testicles.  If,  however,  at  the  end 
of  the  third  month,  when  differentiation  of  sex  is  manifested,  the  geni- 
tal glands  develop  into  ovaries,  the  Wolffian  body  and  canal  atrophy, 
almost  disappearing,  and  leave  as  their  only  remnant  the  organ  of  Eo- 
senmiiller  in  the  broad  ligament.  Mliller's  duct,  however,  persists,  and 
from  it  are  developed  the  Fallopian  tubes,  while  the  round  ligament  is 
developed  from  the  yet  persisting  ligament  of  the  Wolffian  body,  blend- 
ing, however,  with  Mliller's  ducts  at  the  Junction  of  the  superior  with 
the  middle  third.  The  external  organs  of  generation  are  derived  from 
the  genital  tubercle,  which  appears  at  about  the  sixth  week  of  festal 
life  and  reaches  its  maturity  during  the  succeeding  two  weeks.  After 
the  development  of  the  genital  folds  and  at  the  end  of  the  second 
month  there  is  recognisable  on  its  posterior  surface  a  furrow  extending 
in  the  direction  of  the  cloaca  and  designated  the  genital  groove.  This 
is  the  beginning  of  sex  development,  the  subsequent  steps  of  which, 
as  outlined  by  Pozzi,  are  as  follows:  "  The  genital  groove  does  not  close 
more  in  front  than  behind,  and  thus  the  female  lacks  the  clitoridian 

117 


118  A  TEXT-BOOK  OF   GYNECOLOGY 

|)ortion  of  the  urethra:  and  this  canal  in  tlie  adult  opens  at  a  point 
homologous  Avith  that  where  it  was  found  in  the  foetus  of  eight  weeks — 
a  disposition  which  is  found  in  the  male  when  the  proper  development 
of  the  parts  has  been  arrested  (hypospadias).  The  corpus  spongiosum 
of  the  urethra^  the  product  of  the  erectilized  borders  of  the  genital 
furrow,  is  also  completely  develojaed  in  the  male  and  entirely  sur- 
rounds the  canal  in  the  pendulous  portion.  But  in  the  female  it  aborts 
in  the  intermediate  or  vestibular  portion,  being  reduced  below  to  its  two 
extremities  extending  to  the  bulb  of  the  vestibule,  homologue  of  the 
bulb  of  the  male  urethra,  but  divided  by  the  persistent  genital  opening; 
and  above,  it  forms  the  glans  of  the  chtoris,  wliich  covers  the  corpora 
cavernosa  clitoridis,  homologaies  of  the  similar  structures  in  the  male 
penis.  At  the  internal  part  of  the  bulb  of  the  vestibule  there  are  ves- 
tiges of  a  membranous  organ,  which  reaches  its  full  development  in  the 
male — namely,  the  bulb  of  the  urethra;  it  is  this  which  forms  the  hymen. 
Above,  joining  bulb  and  hymen  to  the  clitoris  and  representing  the  ver- 
tical or  cylindrical  portion  of  the  masculine  corpus  spongiosum,  there  is 
in  the  female  a  band  with  a  vascular  bundle  running  into  it,  the  frsnum 
masculinum  vestibuli."    (Medical  and  Surgical  Gynecology ,Yo\.ii,\:>. 4:o() .) 

When  the  ducts  of  ]\Iuller  coalesce  by  the  approximation  of  their 
internal  thirds  they  naturally  form  a  bifurcating  double  tube  divided 
at  the  lower  extremity  by  a  septum  with  two  divergent  ends  above.  xVs 
development  progresses  this  septum  disappears,  leaving  the  rudimen- 
tar})-  vagina  below  and  the  rudimentary  Fallopian  tubes  above  with  no 
intervening  uterine  body.  At  the  end  of  the  fifth  month,  however, 
there  occurs  at  the  upper  end  of  this  rudimentary  vagina  a  deposit  of 
tissue,  which  marks  the  beginning  of  the  uterus.  The  failure  of  the 
septum  to  disappear  from  the  rudimentary  vagina  results  in  the  devel- 
opment of  a  double  vagina;  while  its  disappearance  from  the  vagina, 
but  its  failure  to  disappear  from  the  uterine  extremity  of  the  rudi- 
mentary canal,  results  in  the  development  of  a  double,  or  bicornate, 
uterus.     (See  Malformations.) 

Malformations  of  the  vulva  may  lead  at  the  time  of  birth  to  an 
erroneous  declaration  of  the  sex  of  the  individual,  and  later  on  they 
may  disqualify  for  marriage;  the  importance  of  vaginal  anomalies  usu- 
ally becomes  apparent  when  labour  is  in  progress;  and  the  structural 
irregularities  of  the  h}Tnen  commonly  produce  menstrual  retention  at 
the  epoch  of  puberty,  or  interfere  with  the  consummation  of  the  act 
of  coition  some  years  afterward. 

]\rALFOEMATIO>rS    OF    THE    VULVA 

The  embryology  of  the  vulva  is  less  clearly  understood  than 
that  of  the  uterus;  it  is  in  consequence  of  this  that  its  malfor- 
mations have  not  been  so  completely  systematized  as  have  those  that 
affect  the  uterus.  When  the  changes  which  take  place  at  the  poste- 
rior end  of  the  embryo  in  connection  with  the  development  of  the 


THE  EXTERNAL   ORGANS  OF   GENERATION  IN  WOMEN       II9 


;genital  tubercle,  the  cloaca,  and  the  urogenital  sinus,  are  better  known, 
the  anomalies  which  arise  from  interference  with  the  normal  course 
of  these  changes  will  be  more  easily  comprehended.  The  complexity 
of  the  embryogenesis  of  the  neighbourhood  of  the  Bauchstiel  is  in- 
creased by  the  occurrence  of  transitory  structures  or  scaffoldings  which 
give  place  in  time  to  the  permanent  arrangement  of  parts,  but  which 
may,  under  certain  circumstances,  persist  more  or  less  completely,  and 
thus  give  rise  to  malformations.  A  good  instance  of  this  permanence 
■of  temporary  scaffoldings  is  found  in  atresia  ani  vaginalis. 

Vulvar  Atresia. — Complete  absence  of  the  vulva,  the  skin  passing 
unbroken  from  the  symphysis  pubis  to  the  coccyx,  is  a  matter  of  tera- 
tological  interest  solely;  on  the  other  hand,  apparent  vulvar  atresia,  or 
atresia  vulvce  superficialis,  has  an  immediate  importance.  On  account 
'of  the  existence  of  labial  adhesions,  there  is  an  apparent  absence  of  the 
vulvar  cleft  (Fig.  47).  A 
small  opening  exists  an- 
teriorly from  which  the 
urine  issues  sometimes 
"with  considerable  diffi- 
■culty.  At  puberty  trouble 
may  arise  through  the  oc- 
■currence  of  hematocol- 
pus;  but  if  the  opening  is 
large  enough  to  permit 
the  escape  of  the  men- 
:strual  fluid,  the  discovery 
■of  the  anomaly  is  post- 
poned till  marriage,  when 
.attemjDts  at  ]3enetration 
iDy  the  husband  may  suc- 
■ceed  in  breaking  down 
"the  labial  adhesions  or 
may  require  to  be  supple- 
mented by  the  knife  of 
the  surgeon.  It  is  note- 
ivorthy  that  while  this 
:atresic  condition  may  pre- 
vent coitus,  it  is  not  a 
•complete  obstacle  to  im- 
pregnation. The  treat- 
ment is  simple  :  some- 
times the  labia  can  be 
torn  apart,  as  was  done 
by  Jan  (Indian  Lancet, 
vol.  vii,  p.  123,  1896);  at 

other  times  it  may  be  necessary  to  pass  a  sound  in  at  the  anterior  open- 
ing (Fig.  48),  to  direct  it  Imckward,  and  then  to  cut  down  ujwn  it  (Coop, 


Fio.  47. — "On  acco\int  of  tlie  existcnc-r  nf  labial  adhe- 
sions, there  is  an  apparent  absence  of  the  vulvar 
cleft." — Ballantyne. 


120 


A  TEXT-BOOK  OP   GYNECOLOGY 


American  Gynecological  and  Obstetrical  Journal,  vol.  vi,  p.  594,  1895). 
When  the  atresia  of  the  vulva  is  associated  with  hypertrophy  of  the 
clitoris,  doubts  as  to  the  sex  of  the  individual  may  arise. 

An  anomaly  closely  allied  to  that  just  described  consists  in  the 
existence  of  preputial  and  labial  adhesions  binding  down  the  clitoris. 

This  leads  to,  or  is  at 
least  associated  with,, 
nervous  derangements, 
both  in  childhood  and 
adult  life.  The  freeing 
of  the  clitoris  from  these 
adhesions  may  be  fol- 
lowed by  the  disappear- 
ance of  symptoms,  in  this 
respect  resembling  the 
effect  of  circumcision  in 
the  male. 

Infantile  Vulva. — In 
infancy  the  labia  majora 
are  less  developed  in 
comparison  with  the 
other  parts,  and  the  vul- 
var cleft  is  consequently 
more  exposed  to  view; 
the  mons  also  is  but 
slightly  marked,  and 
there  is  an  absence  of 
hair.  These  infantile 
characters  may  persist  in 
adult  life.  In  individuals, 
showing  this  persistence,  there  is  commonly  also  an  imperfect  develop- 
ment of  the  uterus,  ovaries,  and  mammary  glands;  chlorosis  may  be  pres- 
ent, and  the  whole  clinical  picture  may  be  called  infantilism  in  woman. 
Double  Vulva. — Only  three  cases  (those  reported  by  Le  Cat,  1765; 
Suppinger,  1876;  and  Chiarleoni,  1891)  are  on  record  in  which  individ- 
uals, otherwise  single  in  formation,  possessed  two  vulvse  situated  side 
by  side  in  the  interfemoral  space.  In  two  of  these  there  was  an  im- 
perforate condition  of  the  anus,  the  rectum  opening  into  the  vulva  or 
into  the  vagina.  A  case  in  which  the  external  genital  organs  of  both 
sexes  were  present  was  reported  by  Moostakoff  in  a  Bulgarian  Journal 
{Meditzina,  p.  32,  1894;  abstract  by  Ballantyne  in  Teratologia,  vol.  ii, 
p.  234,  1895),  and  a  similar  instance  (Fig.  49)  has  been  described  by 
ISTeugebauer  (Monatsshrift  fiir  Gedurtshiilfe  und  Gynakologie,  Bd.  vii,  p. 
550,  1898).  It  is  probable  that  in  both  these  latter  cases  the  two  sets 
of  organs  were  really  of  the  same  sex,  one,  however,  being  so  deformed 
as  to  resemble  the  appearance  presented  by  the  part  of  the  opposite  sex. 
The  corresponding  malformation  in  the  male  is  diphallus,  or  double 


Fig.  48. — "  It  may  be  necessary  to  pass  a  sound  in  at 
the  anterior  opening." — Ballantyne  (page  119). 


THE   EXTERNAL   ORGANS  OP  GENERATION  IN   WOMEN      121 

penis,  twenty  cases  of  which,  including  one  personal  observation, 
Ballantyne  and  Skirving  {Teratologia,  Bd.  ii,  p.  92,  184,  255,  1895) 
gathered  together  and  analyzed.  Both  in  diphallus  and  in  double  vulva 
there  is  good  reason  to  believe  that  the  anomaly  is  truly  a  duplication 
of  the  lower  end  of  the  trunk — that  it  is,  in  fact,  the  least  degree  of 
posterior  dichotomy.  This  view  is  strongly  supported  by  the  fact 
that  in  several  of  the  cases  that  have  been  dissected  there  has  been 
discovered  bifidity  of  the  lower  end  of  the  vertebral  column  as  well  as 
duplication  of  the  external  genital  organs.    Ballantyne  has  reported  an 


Fig.  40. — "A  caso  in  which  the  external  genital  organs  of  both  sexes  were  present." — 
Ballantyne  (page  120). 

instance  of  double  genital  tubercle  (without  any  other  trace  of  exter- 
nal genitals)  in  a  foetus  with  exomphalos  and  sacral  meningocele 
(Transactions  of  the  Edinburgh  Obstetrical  Society,  vol.  xxiii,  p.  36, 
1898). 

Persistent  Cloaca. — Under  the  various  names  of  anus  vulvalis,  vul- 
var anus,  atresia  ani  vaginalis,  atresia  ani  vestibularis,  and  vulvo- 
vaginal anus,  has  been  described  an  anomaly  which  is  really  due  to  the 
persistence  of  the  cloacal  stage  of  the  development  of  the  female  gen- 
erative organs.  There  is  no  anal  opening  in  the  normal  position,  but 
faicos  pass  from  the  vagina  (Fig.  50).     Examination  reveals  an  open- 


122 


A  TEXT-BOOK  OF   GYNECOLOGY 


ing,  which  may  be  pinhole  in  size^  in  the  neighbourhood  of  the  hymen 
or  at  a  slightly  higher  level  in  the  vagina;  this  is  the  lower  end  of 
the  rectum.  J.  AY.  Ballantyne  has  recently  had  a  case  brought 
Tinder  his  notice  by  Dr.  George  Elder,  in  which,  in  a  girl  four  months 
•old,  there  were  two  vulvar  anal  openings  between  the  posterior  com- 
missure and  the  hymen;  there  was  a  dimple  where  the  normal  anus 

should  have  been. 
Sometimes,  but  rare- 
ly, the  anomaly  co- 
exists with  a  normal 
anal  opening.  It  is 
noteworthy  that  in 
quite  a  number  of  the 
reported  cases  there 
was  control  over  the 
motions.  Under  such 
circumstances  the 
malformation  might 
pass  unrecognised  till 
after  marriage  or  the 
occurrence  of  labour. 
When,  however,  there 
is  fascal  inconti- 
nence, operation  be- 
comes imperative. 
The  time  of  puberty 
is  that  best  suited 
for  interference;  and 
it  is  commonly  rec- 
ommended that  a 
probe  be  passed  in 
at  the  vulvar  end  of 
the  fistiilous  tract 
and  brought  out  at 
the  spot  where  the  anus  ought  to  be,  and  that  the  structures  be- 
tween the  director  and  the  surface  of  the  perineum  be  divided  and 
the  rectum  pulled  doAvn  and  fixed  by  sutures.  Buckmaster  {Transac- 
tions of  the  American  Gynecological  Society,  vol.  xix,  p.  275,  1894), 
however,  advises  that  the  rectal  canal  be  brought  down  in  front  of  the 
sling  formed  by  the  fibres  of  the  levator  ani  muscle  and  fastened  with- 
out strain;  that  a  second  operation  be  performed  for  the  restoration 
of  the  perineum;  and  that  finally  the  fibres  of  the  levator  ani  be  split 
so  as  to  form  a  sphincter  very  much  as  has  been  done  with  the  rectus 
muscle  in  gastrostomy. 

Persistent  TJrog-enital  Sinus. — The  name  hypospadias  in  woman  has 
been  given  to  the  condition  in  which  the  urethra  appears  to  open  into 
the  vagina  at  a  higher  level  than  is  normal  (Fig.  51);  this  is  really 


Pig.  50. — "  Tliere  is  no  anal  opening  in  the  normal  position, 
but  feces  pass  from  the  vagina." — Ballantyne  (.page  121). 


THE   EXTERNAL   ORGANS  OP   GENERATION  IN  WOMEN       123 


persistence  of  the  urogenital  sinus,  for  what  is  called  the  lower  end  of 
the  vagina  in  tliese  cases  is  more  correctly  described  as  the  urogenital 
sinus.  It  differs  from  persistent  cloaca  in  the  fact  that  the  perineum 
and  anal  opening  are  normally 

formed  and  situated.     There      "  "  ^ 

is  a  greater  or  less  defect  in 
the  posterior  wall  of  the 
urethra.  Clinically,  cases  of 
this  kind  will  be  grouped  ac- 
cording as  there  is  or  is  not  in- 
continence of  urine.  If  there 
is  no  incontinence,  as  in  the 
case  reported  by  W.  A.  Ed- 
wards (American  Gynecological 
and  Obstetrical  Journal,  vol. 
vi,  p.  449,  1896),  the  individ- 
ual may  pass  through  life  and 
even  give  birth  to  children 
without  the  anomaly  being  de- 
tected. But  in  the  other  case 
it  will  be  necessary  to  operate, 
and  the  method  of  Gersuny 
may  be  adopted,  as  was  done 
with  success  by  Krajewski 
(Bitner,  Przeglad  CJiirurgicz- 
ny,  vol.  i,  p.  260,  1893-'94). 
The  urethra  is  dissected  out 
up  to  the  neck  of  the  bladder, 
the  slit  in  its  posterior  wall  is 

stitched,  the  canal  is  then  twisted  on  its  long  axis,  and  fixed  in  position 
by  a  series  of  sutures. 

Epispadias  in  Women. — In  women  epispadias  may  be  met  with  as  a 
part  of  the  malformation  known  as  extroversion  of  the  bladder,  or  it 
may  exist  practically  alone.  To  the  latter  condition  the  name  is  best 
restricted.  Ballantyne  (EdinhurgJi  Hospital  Reports,  vol.  iv,  p.  349, 
1896)  has  described  a  case  of  this  kind  and  gathered  together  thirty-two 
others  from  literature.  It  consists,  as  in  Dranitzin's  case  (Journal 
ATcush.,  vol.  viii,  p.  567,  1894),  in  the  absence  of  a  greater  or  smaller 
part  of  the  anterior  wall  of  the  urethra,  Avith  the  division  of  the  cli- 
toris into  two  parts,  and  the  presence  of  a  median  groove  in  the  region 
of  the  anterior  commissure  of  the  vulva  (Fig.  52).  There  is  no 
splitting  of  the  symphysis  pubis  or  anterior  bladder  wall.  It  has  only 
one  symptom — more  or  loss  complete  urinary  incontinence — and  in  its 
least  marked  form  (clitoi-idian  epispadias)  even  this  may  be  absent. 
Various  plastic  operations,  resembling  those  used  in  hypospadias,  have 
been  employed  to  lengthen  and  narrow  the  urethra  and  to  restore  the 
anterior  vulvar  coiiiinissui-e  and  eliloi-is;  but  success  has  only  been  occa- 


FiG.  51. — "  The  name  hypospadias  has  been  given 
to  the  condition  in  which  the  urethra  appears 
to  open  into  the  vagina  at  a  higher  level  than 
is  normal." — Ballantyne  (page  122). 


124: 


A  TEXT-BOOK  OF  GYNECOLOGY 


sionally  obtained,  and  most  often  the  purely  palliative  wearing  of  a 
urinal  has  had  to  be  accepted  as  the  sole  treatment  practicable. 

Precocious  Development 
of  the  "Vulva. — In  strong  con- 
trast to  the  cases  of  infantile 
vulva  are  those  of  precocious 
development  of  it,  which  are 
occasionally  met  with.  Girls 
of  from  two  to  ten  years  ex- 
hibit under  these  circum- 
stances a  marked  growth  of 
pubic  hair;  the  vulva,  as  in 
the  adult,  is  strongly  devel- 
oped anteriorly  (de  Eiche- 
mond,  Revue  mensuelles  des 
maladies  de  Venfance,  tome 
xvii,  p.  74,  1899);  and  the 
mammary  glands  may  also 
show  hypertrophy.  Physio- 
logically there  may  be  early 
menstruation  or  pubertas 
precox  (Hennig,  Centralblatt 
filr  Gynakologie,  Bd.  xxii,  p. 
832,  1898),  and  in  some  in- 
stances (e.  g.,  that  reported 
by  C.  W.  Gleaves,  Medical 
Record,  New  York,  November 
16,  1895)  there  has  been  pre- 
cocious pregnancy. 

Malformations  of  the 
Labia,  Clitoris,  and  Peri- 
neum.— The  anomalies  that 
have  been  described  affect  more  or  less  all  the  structures  mak- 
ing up  the  vulva,  but  the  single  parts  may  also  be  malformed.  The 
labia  minora  or  nymphse  may  be  absent,  or  increased  in  number,  or 
hypertropMed;  the  clitoris  also  may  be  enlarged  so  as  to  suggest  doubts 
as  to  the  real  sex  of  the  individual.  In  many  of  these  cases  of  hyper- 
trophy there  exist  nervous  phenomena,  which  are  occasionally  miti- 
gated by  excision  of  the  enlarged  parts.  A  curious  anomaly  of  the  labia 
minora  has  recently  been  reported  by  Shoemaker  {American  Journal  of 
Obstetrics,  vol.  xxxii,  p.  216,  1895);  the  nymphas  were  unusually  large, 
and  in  each  there  was  a  congenital  circular  perforation  about  half  an 
inch  in  diameter,  and  exactly  opposite  each  other.  J.  W.  Ballantyne 
has  described  a  case  of  a  suspected  "  hermaphrodite  "  in  which  the 
left  nympha  was  enlarged,  pyramidal,  and  divided  into  two  parts  by  a 
constriction  (Transactions  of  the  Edinlurgh  Obstetrical  Society,  vol. 
xiii,  p.  185,  1898). 


Fig.  52. — "Epispadias  may  lie  met  with  as  part 
of  the  malformation  known  as  extroversion  of 
the  bladder." — Ballantyne  (page  123). 


THE   EXTERNAL   ORGANS  OP   GENERATION  IN  WOMEN       125 


Pseudo-hermaphroditism :  Masculine. — It  is  not  out  of  place  in  a 
work  devoted  to  gynecology  to  refer  to  cases  of  doubtful  sex  in  which 
the  individual,  by  reason  of  his  possession  of  testicles,  is  a  male,  but  on 
account  of  his  external  organs  might  quite  well  be  a  woman,  for  such 
cases  usually  are  brought  to  gynecologists  for  treatment.  The  anomaly 
most  commonly  met  with  under  these  circumstances  is  perineo-scrotal 
hypospadias  (Fig.  53).  The  imperforate  penis,  often  atrophic,  re- 
sembles the  clitoris;  the  ure- 
thra opening  at  the  base  of 
this  rudimentary  penis  re- 
sembles the  female  meatus 
urinarius  at  the  base  of  the 
vestibule;  and  the  short  ves- 
tibular canal,  which  may 
even  be  guarded  by  a  hymen, 
simulates  the  vaginal  orifice 
in  a  very  striking  fashion. 
Nondescent  or  atrophy  of  the 
testicles,  enlargement  of  the 
mammary  glands,  and  the 
exhibition  of  acquired  femi- 
nine traits,  may  all  combine 
to  make  the  question  of  the 
sex  of  the  hypospadic  male 
one  of  the  greatest  difficulty. 
When  it  is  added  that  cases 
have  occurred  in  which  the 
individual  not  only  possessed 
a  uterus,  but  also  sufEered 
every  month  from  a  san- 
guineous discharge  from  it, 
the  discovery  of  the  true  sex 
only  after  post  -  mortem 
microscopic  examination  of 
the  genital  glands  can  be 
quite  well  understood.  It 
must  also  be  remembered 
that    the    testicles    in    such 

cases  often  show  pathologic  changes.  In  an  individual  described  by 
P.  Delageniere  (Annales  de  gynecologie,  tome  li,  p.  57,  1899),  and 
regarded  for  twenty-seven  years  as  a  woman,  the  testicles,  which  were 
found  in  the  inguinal  regions,  showed  tubules  surrounded  by  fibrous 
tissue,  atrophied,  and  containing  no  spermatozoa.  In  one  of  the 
glands  there  were  also  several  nodules,  "adenomata  of  the  testicle." 
In  this  case  the  vulva  was  absolutely  normal,  the  breasts  were 
those  of  a  girl  before  puberty,  and  the  thorax  was  mascuhne  in 
type.     'J'lie  abflomon  was  opened,  but  no  trace  was  found  of  uterus  or 


Fig.  53. — "  The  anomaly  most  commonly  met  with 
is  perineo-scrotal  hypospadias." — Ballantyne. 


126  A  TEXT-BOOK   OP   GYNECOLOGY 

tubes;  the  atrophied  testicles  were  removed.  If  such  individuals  are 
seen  at  the  time  of  birth  it  is  probably  best  to  bring  them  up  as  boys, 
as  Lawson  Tait  suggests,  for  male  pseudo-hermaphrodites  are  com- 
moner than  females,  and  there  is  less  risk  in  bringing  up  a  girl  among 
boys  than  a  boy  among  girls.  At  a  later  age  the  question  of  removal 
of  the  genital  glands  (nearly  always  atrophic  or  morbid  either  in 
structure  or  position)  will  require  to  be  faced.  C.  Martin  has  removed 
the  testicles  from  an  individual  brought  up  as  a  girl,  with  the  result  or 
sequence  that  the  pubic  hair  and  the  breasts  developed  {British  Medical 
Journal,  vol.  i,  1894,  p.  1361);  but  it  is  doubtful  to  what  extent  we  are 
at  liberty  in  these  cases  to  remove  sexual  glands  even  when  these  are 
in  all  probability  morbid  in  structure  and  jDossibly  functionally  inade- 
quate. 

Pseudo-hermaphroditism :  Feminine. — The  most  common  form  of 
gynandria  or  feminine  pseudo-hermaphroditism,  is  that  in  which 
superficial  vulvar  atresia  exists  in  association  with  hypertrophy  of  the 
clitoris.  When  there  is  also  hernia  of  the  ovaries  into  the  labia  the 
individual  may  readily  be  regarded  as  a  male.  In  all  probability,  how- 
ever, doubts  will  early  arise  as  to  the  true  sex,  and  a  close  inspection  of 
the  parts,  accompanied  possibly  by  some  slight  surgical  interference, 
will  serve  to  make  plain  the  matter  before  any  harm  is  done. 

Malformations  of  the  Vagina 

The  embryology  of  the  vagina  is  better  understood  than  that  of  the 
vulva,  and  the  nature  of  its  anomalies  is  therefore  more  evident.  Some 
doubt,  however,  exists  as  to  the  mode  of  formation  of  the  lower  end  of 
the  canal  and  of  the  hymen.  The  general  view  is  that  the  whole  of 
the  vagina  above  the  hymen  is  Miillerian  in  origin,  being  produced  by 
canalization  of  the  fused  lower  ends  of  the  two  ducts  of  Mliller;  but 
Berry  Hart  (Transactions  of  the  Edinburgh  Obstetrical  Society,  vol. 
xxii,  p.  18,  1897)  looks  upon  it  as  Miillerian  in  its  upper  part  only,  and 
as  developed  from  the  urogenital  sinus  in  its  loAver  third  by  the  break- 
ing down  of  cells  derived  from  the  Wolffian  bulbs  (lower  ends  of  the 
Wolffian  ducts).  ISTagel's  investigations,  however,  do  not  support  Hart's 
conclusions,  and  Webster  {Transactions  of  the  American  Gynecological 
Society,  vol.  xxiii,  p.  446,  1898)  also  sums  up  adversely  to  them.  Nev- 
ertheless the  anomalies  of  the  vagina  present  features  not  easily  ac- 
counted for  by  either  of  the  two  theories  of  origin. 

Absence  of  the  Vagfina. — Cases  of  complete  absence  of  the  vagina, 
in  which  careful  examination  of  the  tissues  lying  between  the  rectum 
and  the  bladder  reveals  no  trace  of  muscular  bands,  are  of  pathological 
interest  solely;  they  occur  only  in  connection  with  advanced  terato- 
logical  conditions,  such  as  sympodia. 

Vaginal  Atresia. — There  may  exist  a  complete  or  an  incomplete 
imperforate  condition  of  the  vagina;  between  the  bladder  and  rectum 
there  may  be  found  simply  a  fibro-muscular  cord;  in  other  cases  the 


THE  EXTERNAL  ORGANS  OF  GENERATION  IN  WOMEN   127 


vaginal  canal  may  be  present  in  part  and  imperforate  in  part;  and  in 
yet  others  there  may  be  a  membranous  septum  at  the  upper^  middle,  or 
lower,  third  of  the  vagina.  When  the  lower  third  of  the  canal  alone 
is  present  it  is  surmised  that  it  is  not  Mtillerian,  but  derived  from  the 
vestibular  sinus;  its  upper  boundary  would  be  composed  of  the  lower 
imperforate  end  of  the  Miillerian  vagina,  or  (if  the  theory  of  Hart  is 
accepted)  of  the  persistent  Wolffian  bulbs.  The  malformed  state  of  the 
vagina  is  commonly  associated  with  anomalies  in  the  other  genital 
organs  both  internal  and  external;  thus,  the  uterus  may  be  ill  devel- 
oped or  absent,  and  the  Fallopian  tubes  and  vulva  may,  but  not  so 
frequently  as  the  uterus,  be 
defective.  On  the  other 
hand,  the  uterus  and  the 
other  genitals  may  be  normal 
in  structure.  Sometimes  it  is 
stated  that  the  ovaries  are 
absent,  but  it  must  be  re- 
marked that  in  cases  in 
which  the  vagina  and  ovaries 
are  both  absent  the  sex  of  the 
individual  can  hardly  be  re- 
garded as  female  at  all.  If 
functionally  active  ovaries 
and  uterus  coexist  with  im- 
perforation  of  the  vagina, 
the  supervention  of  puberty 
usually  leads  to  the  retention 
of  blood,  in  a  more  or  less 
altered  state,  in  the  uterus 
(hematometra)  or  tubes 
(hematosalpinx),  or  in  the 
perforate  part  of  the  vagina 
(hematocolpus)  (Fig.  54).  J. 
W.  Ballantyne  has  recently 
seen  a  case  (under  the  care 
of  Dr.  Alexander  James  in 
the  Edinburgh  Infirmary)  in 
which  the  vagina  was  imper- 
forate in  a  great  part  of  its 

extent,  and  in  which  the  uterus  was  the  size  of  a  three  months'  preg- 
nancy (hematometra);  the  patient,  a  girl  twenty-two  years  of  age,  had 
frequently  recurring  attacks  of  epistaxis,  and  a  very  remarkable  fea- 
ture of  the  morbid  anatomy  was  the  presence  of  well-marked  cervi- 
cal ribs. 

('linically,  an  impoi-forate  condition  of  the  vagina  usually  begins  to 
attract  notice  when  the  indi vicinal  reaches  the  age  of  puberty.  As 
month  after  month  goes  past  without  any  sign  of  the  menstrual  dis- 


FiG.  54. — "  The  supervention  of  puberty  usually 
leads  to  the  retention  of  blood  in  the  perforate 
part  of  the  vagina  (hematocolpus)." — Ballan- 
tyne. 


128  ^  TEXT-BOOK  OF   GYNECOLOGY 

charge,  but  with  all  the  signs  associated  with  menstruation  (pain  and 
weight  in  the  pelvis,  headache,  swelling  of  the  breasts,  epistaxis,  etc.), 
the  patient^s  friends  bring  her  to  a  medical  practitioner.  It  is  then 
found  that  the  vagina  is  imperforate  and  that  there  is  distention  in  the 
hypogastric  region,  and,  if  the  case  is  kept  under  observation,  it  may 
be  noted  that  this  swelling  increases  suddenly  at  recurring  monthly 
periods,  to  diminish  again  slowly  in  the  intervals.  The  examining 
finger  passes  into  the  vagina  to  a  greater  or  lesser  distance,  accord- 
ing as  the  imperforation  is  high  up  or  low  down  in  the  canal,  but  it 
never  touches  the  cervix,  and  by  the  aid  of  the  rectal  touch,  with  a  sound 
in  the  bladder  perhaps,  it  can  be  made  out  whether  the  uterus  and 
adnexa  are  present  or  not,  and  whether  there  is  menstrual  retention  in 
the  uterus  and  tubes  or  not.  In  other  cases  of  vaginal  atresia,  the  first 
symptoms  to  lead  to  medical  intervention  are  those  arising  at  the  time 
of  marriage,  when  coitus  is  found  to  be  either  impossible  or  incomplete 
and  painful.  In  these  instances  the  internal  genital  organs  may  be 
functionally  quiescent,  a  fact  which  accounts  for  the  absence  of 
monthly  suffering  and  for  the  late  discovery  of  the  vaginal  anomaly. 

The  intervention  of  the  gynecologist  in  cases  of  imperforate  vagina 
may  be  rendered  necessary  under  two  sets  of  circumstances — at  or  soon 
after  puberty,  for  monthly  pain  and  for  hematometra  and  the  symp- 
toms associated  therewith;  or  at  the  time  of  marriage  for  dyspareunia. 
Under  the  former  circumstances,  the  object  of  intervention  is  to  reach 
and  evacuate  the  retained  menstrual  blood;  under  the  latter,  it  is 
mainly  to  establish  what  may  be  called  a  coitional  vagina  by  a  plastic 
operation. 

If  the  vaginal  atresia  is  situated  near  the  introitus  and  is  localized, 
then  a  simple  crucial  incision  will  serve  to  set  free  the  more  or  less 
altered  blood  in  the  upper  part  of  the  canal;  the  evacuation  should  be 
•carried  out  without  haste  and  strict  surgical  cleanliness  observed.  If, 
on  the  other  hand,  the  atresia  is  extensive  and  the  blood  accimiulation 
is  far  from  the  surface,  very  careful  dissection  will  be  needed  before  the 
cervix  uteri  is  reached.  With  the  sound  in  the  bladder  and  a  finger  in 
the  rectum,  and  using  the  handle  of  the  knife  or  probe-pointed  scissors, 
the  operator  will  work  upward  toward  the  blood  accumulation  (whose 
position  has  been  determined  by  rectal  touch),  will  incise  the  sac,  and 
endeavour,  with  the  aid  of  flaps  derived  from  the  labia  minora  and 
perineum,  to  form  a  vaginal  canal.  Possibly  in  the  future  the  method 
of  operating  recommended  by  P.  Walton  (Belgique  medicale,  ann.  5,  p. 
353,  September  22,  1898)  will  take  the  place  of  that  described  above  as 
more  speedy  and  scarcely  more  dangerous.  He  makes  an  H -shaped 
incision  between  the  labia  minora,  dissects  upward,  and  at  once  opens 
into  the  peritoneal  cavity  (instead  of  avoiding  it,  as  has  been  the  cus- 
tom) through  the  pouch  of  Douglas;  he  then  passes  his 'fingers  in  and 
ascertains  the  condition  of  the  uterus  and  adnexa;  the  opening  in  the 
peritoneum  can  then  be  closed  with  catgut  sutures  and  the  construction 
of  the  artificial  vagina  proceeded  with.    In  the  case  operated  upon  by 


THE   EXTERNAL   ORGANS  OF   GENERATION  IN   WOMEN       129 

Walton,  five  mouths  had  elai^sed  since  the  formation  of  the  canal  and 
menstruation  had  occurred  regularly,  although  in  small  amount  and 
with  complete  absence  of  suffering.  The  results  recently  obtained  by 
posterior  colpotomy  for  other  conditions  support  Walton  in  his  recom- 
mendation; certainly  the  operation  is  greatly  shortened,  and  an  accu- 
rate knowledge  of  the  position  and  condition  of  the  parts  is  obtained. 

It  is  doubtful  to  what  extent  the  gynecologist  is  justified  in  recom- 
mending the  creation  of  an  artificial  vagina  when  no  menstrual  suffer- 
ings exist,  and  when  there  is  consequently  no  reason  to  suppose  that 
functional  internal  organs  are  present,  for  the  operation,  which  is  not 
free  from  risk,  is  manifestly  being  undertaken  solely  to  provide  a 
coitional  vagina.  Should  intervention,  however,  be  decided  upon,  it 
will  be  best  to  dissect  upward  in  the  space  between  the  rectum  and 
bladder  to  a  distance  of  about  two  inches,  and  then  to  line  this  in- 
vagination with  tissue  obtained  from  the  nymphge  and  perineum.  The 
cavity  will  require  to  be  kept  open  for  some  time  with  a  cone-shaped 
pessary. 

Vaginal  Stenosis. — An  abnormal  degree  of  narrowness  of  the  vagina 
may  be  met  with  and  may  affect  the  whole  canal  or  only  a  part  of  it. 
When  the  stenosis  is  general,  it  probably  means  that  we  have  to  do  with 
a  half  vagina  derived  from  one  Mlillerian  duct,  the  other  half  being 
undeveloped,  or  at  least  imperforate.  Then  the  condition  may  be  asso- 
ciated with  the  uterus  unicornis  or  bicornis  (with  one  cornu  rudimen- 
tary). In  other  cases  the  stenosis  is  annular,  and  consists  of  one  or 
more  perforated  diaphragms,  a  condition  which  may  have  been  pro- 
duced by  adhesive  colpitis  in  infancy  or  in  foetal  life,  but  which  more 
probably  represents  incomplete  canalization  of  the  vaginal  anlage. 
Dyspareunia  may  result  at  the  time  of  marriage,  or  delay  may  occur 
during  the  second  stage  of  labour,  and  the  anomaly  thus  be  brought 
under  the  notice  of  the  gynecologist.  It  is  usually  recommended  that 
a  crucial  incision  be  made  and  the  ring  stretched;  but  it  will  be  more 
satisfactory  to  adopt  the  plan  advocated  by  Yineberg  {American  Gyne- 
cological and  Obstetrical  Journal,  vol.  vi,  p.  250,  1895),  which  consists 
in  excision  of  the  septum  and  the  bringing  together  with  sutures 
of  the  up])er  and  lower  margins  of  the  annular  incision  thus  produced. 

Double  or  Septate  Vag-ina. — The  term  double  vagina  should  in  strict 
accuracy  be  applied  only  to  those  cases  in  which  there  exist  two  uteri 
and  two  vulvar  apertures  in  addition  to  the  two  vagina?;  such  cases,  as 
has  been  stated  already,  are  exceedingly  rare,  and  must  be  grouped 
among  the  double  monstrosities.  On  the  other  hand,  septate  vagina, 
which  is  usually  named  ''  double  "  vagina,  is  much  more  common.  It 
is  due  to  want  of  fusion  of  the  two  Miillerian  ducts  in  their  lower  part; 
it  is  not,  therefore,  an  anomaly  by  excess,  but  by  defect,  an  arrested 
development.  Tlu;  septum  generally  rims  antero-]:)osteriorly,  when,  of 
course,  the  vagina;  are  situated  laterally;  rarely,  as  in  a  case  reported  by 
Forflyce  (Teratolof/ia,  vol.  i,  p.  72,  1894),  the  canals  lie  one  in  front  of 
ilie  oIIhm'  aM(l  tlic  scpliini  is  transverse.  The  septum  may  be  complete 
10 


130 


A   TEXT-BOOK  OF  GYNECOLOGY 


and  may  extend  from  a  point  above  between  the  two  cervices  (there  are 
often  two  vaginal  portions,  indicating  a  double  uterus)  to  the  vulvar 
aperture,  where  it  may  subdivide  that  orifice  and  produce  what  is 
called  a  hymen  hiforis;  on  the  other  hand,  it  may  exist  in  the  upper 
part  of  the  vagina  alone,  or  in  the  lower  part  alone,  or  it  may  show  a 
varying  number  of  perforations. 

Clinically,  septate  vagina  may  give  rise  to  no  symptoms  till  parturi- 
tion occurs,  when,  as  in  a  case  recorded  by  Eanieri  {Annali  cli  ostetricia 
e  ginecologia,  xvi,  p.  473,  1894),  excision  of  the  septum  may  be  needed 
during  the  labour  to  prevent  laceration  of  it,  which  might  entail  also 
laceration  of  the  uterus.  When,  however,  one  or  both  halves  of  the 
vagina  are  imperforate  (a  not  uncommon  occurrence  in  septate  vagina, 

Fig.  55)  symptoms  will 
arise  about  the  time  of 
l^uberty  in  association 
with  the  retention  of 
blood  in  one  or  both 
canals  (unilateral  or 
bilateral  hematocolpus). 
When  unilateral,  this 
condition  has  been  called 
atresia  vagince  lateralis. 
Since  the  retention  of 
blood  may  cause  pain 
in  the  back  and  difficulty 
in  micturition  and  defe- 
cation, it  will  be  neces- 
sary to  incise  (or  better 
to  excise)  the  sac,  clear 
out  its  contents,  and 
j)ack  Avith  iodoform 
gauze  under  antiseptic 
precautions.  In  all  cases 
in  which  an  elastic  swell- 
ing is  found  in  the  vag- 
inal wall,  the  possibil- 
ity of  its  being  an  im- 
perforate half  vagina 
communicating  with  a 
functionally   active   half  ^ 

Fig.  55.-"Both  halves  of  the  vagina  are  impel-  ^^^"^""^    '^°''^'^    ^®    ^°™®  " 

forate."— Ballantyne.  in    mind.       In     a     case 

seen  by  Muret  (Revue 
medicale  de  la  Suisse  romande,  p.  280,  May  20,  1895)  the  better  devel- 
oped half  was  imperforate  and  the  more  rudimentary  one  was  patent. 
Sometimes  the  imperforate  half  communicates  with  the  patent  by 
means  of  a  small  opening,  when  dysmenorrhoea  may  exist  without  com- 


TPIE   EXTERNAL   ORGANS   OF   GENERATION  IN  WOMEN      131 

plete  menstrual  retention.     In  Fordyce's  case   {he.  cit.)  both  halves 
opened  into  the  urethra. 

The  Hymen. — This  structure,  which  marks  the  dividing  line  be- 
tween the  vulva  and  the  vagina,  has  been  carefully  studied  by  Schaeffer 
in  nearly  two  hundred  foetuses.  He  found,  without  exception,  that  as 
early  as  the  fifth  month  the  hymen  was  composed  of  two  lamellse,  the 
inner  being  derived  from  the  vagina,  while  the  outer  appeared  to  be  the 
inner  margin  of  the  vulvar  fold;  and  that  coalescence  of  these  two 
layers  was  not  infrequent.  On  the  vaginal  surface  of  the  hymen  were 
found  transverse  folds,  similar  to  those  in  the  vagina,  between  which 
were  pockets  so  distinct  that,  in  the  event  of  their  occlusion,  they  could 
easily  be  converted  into  retention  cysts.  Irregularities  in  the  distri- 
bution of  these  folds  account  for  those  anomalies  of  the  hymen  which 
are  spoken  of  under  the  names  of  hymen  crenulatus,  dentatus,  carinatus, 
falciformis,  etc.  On  the  vulvar  surface  of  the  hymen  in  the  foetus, 
he  found  numerous  folds  extending  from  the  fossa  navicularis, 
nymphse,  clitoris,  and  meatus.  If  these  observations  meet  with  sufh- 
cient  confirmation,  it  may  be  necessary  to  revise  accepted  theories  of  the 
embryologic  development  of  this  structure.  At  present  it  is  looked 
upon  as  a  remnant  of  the  cloacal  appendage.  In  the  human  embryos 
shortly  after  the  coalescence  of  Miiller's  ducts  it  manifests  itself  by 
an  accumulation  of  epithelia  on  the  posterior  wall  of  the  rudimen- 
tary vagina.  Whether  it  develops  entirely  from  the  vulvar  side  or 
entirely  from  the  vaginal  side,  or,  as  is  more  probable,  in  two  lamellae, 
one  from  either  side,  is  a  matter  of  no  practical  importance.  To  the 
naked  eye  it  presents  the  appearance  of  a  mucous  fold  that  in  many 
instances  is  very  elastic.  The  elasticity  of  this  structure  is  so  pro- 
nounced in  a  number  of  cases  that  it  withstands  repeated  parturition. 
Microscopically,  its  surfaces  are  shown  to  be  covered  with  flat  epi- 
thelium on  a  network  of  fibrous  elastic  tissue,  containing  few  or  no 
muscular  fibres.  Capillary  vessels  and  nerves  are  conducted  by  nu- 
merous papillse  from  the  central  connective  tissues  into  the  epithelial 
structures. 

Malfokmations  of  the  Hymen 

The  hymen  is  a  developmental  relic,  and  is,  therefore,  very  liable 
to  variations  in  form  and  structure.  It  arises  from  the  breaking  down 
of  the  tissue  between  the  sinus  urogenitalis  and  the  lower  end  of  the 
Miillerian  vagina,  and  it  is  possible,  as  Hart  asserts,  that  the  Wolffian 
bulbs  may  contribute  to  its  formation.  In  addition  to  the  well-known 
part  of  it  which  forms  a  crescentic  fold  at  the  posterior  end  of  the 
vulvar  aperture,  the  hymen  consists  of  a  mesial  band  running  forward 
toward  the  clitoris,  and  forming  a  collar  for  the  meatus  urinarius  on 
the  way.  Attention  was  specially  drawn  to  this  forward  extension  of 
th(!  liymen  by  Pozzi  (A'tmales  de  f/yneeolof/ie,  tome  xxi,  p.  257,  1884),  and 
J.  W.  liallantyno  has  described  the  appearances  presented  by  the  mesial 
vestiltiiliic  \)',u\(\  in  rcinulo  infants  (Fig.  56)  (Transactions  of  the  Edin- 


132 


A   TEXT-BOOK   OP  GYNECOLOGY 


fe!K 


durgh  Obstetrical  Society,  vol.  xiii,  p.  188,  1888).    x\nomalies  may  be  met 
witii  in  the  vestibular  portion  as  well  as  in  the  hymen  commonly  so- 

called,  and  even  a  dis- 
tinct projection  may  exist 
(Fig.  57). 

Hymenal  Atresia  or 
Imperforation. — It  is  ex- 
tremely probable  that 
many  of  the  cases  de- 
scribed as  instances  of 
imperforate  hymen  are 
really  examples  of  atresia 
of  the  lower  end  of  the 
vagina,  for  in  some  of 
the  records  the  presence 
of  a  hymenal  membrane 
hidden  by  the  projecting 
vaginal  sac  is  referred  to. 
On  the  other  hand,  nn- 
donbted  cases  of  atresia 
hymenalis  do  occur.  Tlie 
imperforate  condition  of 
the  membrane  gives  rise 
to  symptoms  which  can 
scarcely  be  distinguished 
from  those  of  atresia  of 
the  lower  part  of  the 
vagina.  During  infancy 
some  trouble  may  be 
caused  by  the  retention 
of  mucus  in  the  canal, 
but  it  is  usually  not  till 
puberty  that  the  condition  attracts  notice.  Every  month,  colicky  pains 
recur  with  increasing  severity;  there  is  some  difficulty  with  micturition 
and  defecation,  which  passes  off 
in  the  intermenstrual  period;  there 
may  be  epistaxis  or  vicarious 
hemorrhage  from  the  bladder  or 
bowel;  but  there  is  no  discharge 
from  the  genitals.  Examination 
of  the  patient  at  one  of  these 
epochs  will  reveal  a  fluctuating 
tumour  i^rojecting  to  a  larger  or 
smaller  extent  above  the  symphy- 
sis jDubis,  according  as  the  condi- 
tion has  been  persisting  for  a  longer  or  shorter  time;  and  in  the  vulva 
will  be  seen  a  bulging  membrane,  which  is  the  distended  hymen.     The 


HOPKINS' 


Fig.  56. — "  The  appeunmces  presented  by  the  mesial  ves- 
tibular band  in  female  infants.'' — Ballantyne  (p.  131 ). 


Fig.  57. — "Even  a  distinct  projection  may 
exist"  (section). — Ballantyne. 


THE  EXTERNAL  ORGANS  OP   GENERATION  IN  WOMEN      133 

condition  of  hematocolpus,  which  has  been  thus  produced,  may  be  ac- 
companied by  the  accumulation  of  blood  in  the  uterus  also  (hemato- 
metra).  F.  Neugebauer  {Medycyna,  vol.  xxi,  p.  429,  1893)  has  recorded 
an  unusual  case  of  hymenal  imperforation  without  menstrual  retention, 
the  blood  escaping  through  a  small  opening  at  the  right  side  of  the 
urethra;  the  hymen  is  described  as  consisting  of  two  lamina  (hymen 
hilamellatus) ,  an  external  incomplete  and  an  internal  complete,  so  that 
it  is  likely  that  the  internal  one  was  really  the  lower  end  of  the  imper- 
forate vagina. 

The  first  step  in  the  treatment  of  hymenal  imperforation  consists 
in  the  evacuation  of  the  retained  menstrual  blood.  The  membrane  is 
incised  and  the  fluid  removed  under  antiseptic  precautions,  the  latter 
being  specially  necessary  if  the  uterus  and  Fallopian  tubes  have  shared 
in  the  distention.  The  remnants  of  the  hymen  are  then  excised,  and 
the  edges  are  brought  together  with  sutures.  The  cavity  is  jDacked  with 
iodoform  gauze.  The  removal  of  the  more  or  less  altered  blood  should 
be  done  slowly. 

Double  Hymen. — The  cases  in  which  two  (or  more)  diaphragms 
exist  near  the  vaginal  outlet  should  not,  perhaps,  be  regarded  as  in- 
stances of  double  hymen,  but  rather  as  examples  of  annular  vaginal 
stenosis.  JSTeither  does  the  existence  of  two  openings  in  the  hymen  con- 
stitute a  double  hymen  in  the  strict  sense  of  the  words.  The  term 
ought  to  be  left  for  the  very  rare  instances,  to  which  reference  has 
already  been  made,  in  which  two  vulvae  exist  side  by  side  in  the  inter- 
femoral  region. 

Absence  of  the  Hymen. — The  hymen  is  rarely  completely  wanting 
except  in  connection  with  absence  of  all  the  external  genitals,  as  in 
some  marked  forms  of  monstrosity;  but  it  may  be  apparently  absent, 
being  hidden  from  view  by  the  bulging  lower  end  of  an  imperforate 
vagina.  In  the  newborn  infant,  it  is  folded  together  and  projects  from 
the  vaginal  orifice  as  two  lateral  folds,  which  may  be  taken  for  the 
labia  minora.  In  the  negro  infant,  it  is  deeply  seated,  and  may  in  con- 
sequence be  thought,  on  casual  inspection,  to  be  absent. 

Anomalies  in  the  Form  of  the  Hymen. — Instead  of  its  normal  cres- 
centic  form,  the  hymen  may  be  circular  (Fig.  56),  or  notched  (denticu- 
late), or  projecting  (infundibuliform),  or  fimbriated.  Instead  of  bound- 
ing one  orifice  it  may  show  two  openings,  which  may  be  equal  in  size 
and  situated  laterally  (Jiymen  septus),  or  unequal  in  size  and  situated 
irregularly  {hymen  Ufenestratus);  in  rare  cases  there  may  be  several 
openings  (Jiym^en  crilriformis).  J.  W.  Ballantyne  recently  met  with  an 
instance  of  very  complete  hymen  septus  in  an  unmarried  woman  of 
forty  upon  whom  he  was  operating  for  hemorrhoids;  the  openings  were 
perfectly  equal  in  size,  and  the  septum,  which  was  quite  fleshy,  extended 
for  some  distance  up  the  vagina;  the  uterus  was  single,  as  was  also  the 
w])])('A-  pMPt  of  the  vagina. 

Anomalies  in  the  Structure  of  the  Hymen. — 'I'lu;  hymen,  especially 
in  I'Mcrly  |iriini|)ar'a',  iiuiy  he  v<'iy  tough  and  resistant;  it  may  on  this 


134  A  TEXT-BOOK   OF  GYNECOLOGY 

account  delay  tlie  dilatation  of  the  perineum  in  labour;  it  may  even 
prevent  the  consummation  of  marriage,  and  require  to  be  excised,  as 
in  a  case  seen  by  J.  W.  Ballantyne  (Transactions  of  the  Edinburgh 
Obstetrical  Society,  vol.  xiv,  p.  1-11,  1889).  If  it  is  very  vascular,  as 
well  as  very  tough,  the  laceration  it  undergoes  in  coitus  may  cause 
alarming  hemorrliage. 

Anomalies  in  the  Anterior  Extension  of  the  Hymen  (Urethral 
Hymen  and  Vestibular  Band). — Gilliam  has  described  two  cases  of  what 
would  see]u  to  be  a  persistence  of  the  anterior  extension  of  the  hymen, 
which  surrounds  the  meatus  urinarius  like  a  collar.  In  one  of  these, 
that  of  a  girl  of  eighteen,  suffering  from  incontinence  of  urine,  there 
was  an  anomalous  band  attached  to  the  urethra  and  spreading  itself 
over  the  muscles  of  the  anterior  aspect  of  the  vulvo-vaginal  junction; 
it  was  clipped,  and  the  incontinence  disappeared  at  once.  In  the  other 
case,  that  of  a  girl  of  twenty-one,  also  suffering  from  urinary  inconti- 
nence, a  membrane  stretched  from  the  anterior  segment  of  the  hymen 
and  was  attached  like  wings  to  the  sides  and  under  surface  of  the 
urethra;  its  excision  gave  a  cure.  Gilliam  (American  Journal  of  Ob- 
stetrics, vol.  xxxiii,  p.  ITT,  189G)  thinks  that  these  bands  set  up  local 
irritation. 


CHAPTEE    XIV 

INJURIES   OF   THE   EXTERNAL   GENITAL  ORGANS 

Injuries  of  the  vulva  from  external  violence,  sexual  intercourse,  parturition — Pu- 
dendal hematocele — Injuries  of  the  vagina:  Rupture — Fistulae:  urethro-vag- 
inal,  vesico-vaginal — Sims's  operation — Ross's  operation — Reed's  operation — 
After-treatment  and  dangers — Atresia  of  upper  part  of  urethra — Uretero- 
vaginal  fistulte — Recto-vaginal  fistula — Mayo  Robson's  operation. 

Injueies  of  the  external  organs  of  generation  may,  for  convenience 
of  study,  be  classified  into  those  involving  (a)  the  vulva,  and  (&)  the 
vagina.  On  account  of  the  anatomical  position  of  the  vulva,  which  is 
protected  above  by  the  mons  veneris  and  the  underlying  hard  and 
resisting  symphysis  pubis,  the  descending  rami,  and  the  inner  aspect  of 
the  thighs,  injuries  to  this  structure,  except  when  due  to  parturition, 
are  necessarily  rare. 

The  vascularity  of  the  tissues  composing  the  vulva  predisposes  the 
structure  to  profuse  hemorrhage,  so  that,  should  there  be  a  solution  of 
continuity  of  the  skin,  the  loss  of  blood  may  be  considerable,  even 
amounting  to  syncope  in  weak  and  debilitated  individuals. 

In  considering  these  injuries  the  anatomical  construction  of  the 
surrounding  and  underlying  parts  must  be  borne  in  mind.  The  rami 
of  the  pubis  possessing  a  rather  sharp  inner  edge,  a  blunt  instrument 
may  be  used,  and  yet  an  incised  wound  may  be  the  result,  the  blunt 
object  forcing  the  overlying  soft  structures  against  the  ramus.  Con- 
tused rather  than  incised  wounds  are,  however,  the  rule. 

In  instances  in  which  the  skin  is  not  divided,  hemorrhage  into  the 
abundant  connective  tissue  here  found  results  in  hematoceles  of  vary- 
ing sizes,  according  to  the  size  and  number  of  blood  vessels  injured. 

The  causes  of  these  injuries  to  the  vulva  may  be  considered  under 
three  headings — viz. :  (a)  External  violence,  (&)  coitus,  (c)  parturition. 

External  Violence. — The  patient  may  fall  astride  the  back  of  a 
chair,  as  in  the  case  of  servants  engaged  in  cleaning  windows,  hanging 
curtains,  and  pictures;  or  in  the  case  of  the  female  bicyclist  being 
thrown  from  the  saddle  and  alighting  on  the  iron  frame  or  handle  bar. 
Eoss,  of  Toronto,  reports  {American  Journal  of  Obstetrics,  April,  1898) 
a  case  in  which  a  woman,  while  riding  her  wheel,  was  thrown  from  the 
saddle,  and  alighting  on  the  sharp  portion  of  the  frame,  tore  the  geni- 
talia upward  as  high  as  the  erectile  tissue  near  the  clitoris,  producing 
copious  hemorrhage.     Hemorrhage  from  the  vulva  may  be  fatal  even 

135 


136  A  TEXT-BOOK  OF  GYNECOLOGY 

when  induced  by  a  relatively  slight  injury.  Ford  {New  YorJc  Medical 
Journal)  reports  a  case  of  hemorrhage  resulting  in  death  in  a  patient 
who,  while  at  the  theatre,  in  attempting  to  change  her  seat,  fell  against 
the  iron  partition  between  the  chairs,  inducing  a  lacerated  wound, 
about  a  third  of  an  inch  in  diameter,  between  the  clitoris  and  the 
labium  minus.  If  the  injury  to  the  deeper  structures  is  induced  by 
pressure  against  the  ramus  of  the  pubis  and  does  not  result  in  severing 
the  continuity  of  the  skin,  the  resulting  hemorrhage  takes  the  form 
of  a  hematocele.     (See  Pudendal  Hematocele.) 

Among  other  Avounds  of  the  vulva  are  those  produced  in  children 
while  at  jjlay:  A  fall  upon  a  picket  fence;  splinters  of  wood  being  forced 
into  the  labia  while  sliding  upon  the  floor  or  down  an  incline;  and  falls 
from  sleds  while  coasting,  etc. 

Injuries  to  the  vulva  by  sexual  intercourse,  aside  from  slight  lacera- 
tions of  the  fourchette,  are  of  very  rare  occurrence,  except  in  cases  of 
rape  of  children  and  of  women  of  advanced  age.  In  the  former  they  are 
due  to  the  tender  and  undeveloped  soft  parts,  and  in  the  latter  to  senile 
atrophy  and  consequent  want  of  elasticity.  These  lacerations  generally 
involve  the  hymen  in  the  young  and  the  fourchette  in  the  aged,  and 
extend  thence  in  various  directions.  Baldy  reported  {American  Gyne- 
cological Journal,  1891)  a  case  of  laceration  due  to  first  intercourse, 
the  injury  beginning  at  the  hymen  and  extending  upward  on  the 
vaginal  aspect  of  the  perineum.  Spaeth  records  a  case  {American 
Journal  of  Obstetrics,  1890)  of  laceration  beginning  at  the  vulvar 
orifice,  extending  upward  along  the  posterior  wall  of  the  vagina, 
causing  a  vesico-rectal  fistula. 

Parturition  is  by  far  the  most  frequent  cause  of  injuries  to  the 
pudenda.  (See  Pudendal  Hematocele.)  Here  also  the  perineum  suf- 
fers the  greatest  injury.  Contusions  of  the  labia,  and  sometimes  of  the 
vulvo-vaginal  glands,  are  due,  in  the  majority  of  instances,  to  a  failure 
of  the  head  to  rotate  into  the  conjugate  diameter  of  the  outlet  of  the 
pelvis.  Not  infrequently  also  does  the  careless  use  of  the  forcejDS  cause 
lacerations  and  contusions  of  these  parts. 

Treatment. — The  treatment  of  injuries  of  the  pudenda  does  not  dif- 
fer greatly  from  that  of  like  injuries  inflicted  elsewhere.  The  parts 
should  be  well  shaven,  washed,  and  antisepticized,  and  lacerations  and 
incisions  sewn  up.  If  contusions  only  are  to  be  dealt  with,  the  carbolic 
pack  is  applied.  This  dressing  is  prepared  in  the  following  manner: 
Flakes  of  absorbent  cotton  are  first  saturated  with  a  1-  or  2-per-cent 
solution  of  carbolic  acid,  then  squeezed  out  almost  dry  and  applied 
to  the  antisepticized  injured  |)art.  Over  this  are  applied  flakes  of  dry 
cotton,  and  the  whole  is  covered  with  rubber  tissue  or  oil  silk.  The 
dressing  is  held  in  place  by  a  properly  adjusted  T-bandage.  A  dressing 
thus  applied  will  last  from  six  to  ten  hours.  Further  treatment  is 
given  in  the  section  relating  to  Pudendal  Hematocele. 

Pudendal  hematocele  may  be  the  result  of  a  blow,  a  kick,  or  a 
fall;     or,    in    the    joregnant    state,    of    varices    preceding    labour,    the 


INJURIES  OP   THE   EXTERNAL   GENITAL   ORGANS  137 

pressure  of  the  descending  head,  or  the  unskilful  use  of  forceps. 
M.  A.  Tate,  of  Cincinnati,  who  has  conducted  a  painstaking  research 
on  this  subject  {Lancet-Clinic,  October  17,  1896),  finds  that  it  was 
first  mentioned  by  Kueff',  of  Zurich,  in  1647;  in  1734  by  Kronauer, 
of  Basle;  and  again,  a  hundred  years  later,  by  Deneaux,  from  which  date 
(1830)  reports  of  cases  have  been  relatively  more  frequent.  \^1ien  it 
occurs,  from  whatever  cause,  the  clot  generally  forms  in  one  labium, 
although  in  certain  cases  its  progressive  accumulation  results  in  sepa- 
rating the  connective  tissue  of  practically  the  entire  pudendum.  The 
tumour  thus  formed  may  therefore  vary  in  size  from  very  small  to 
very  large,  Cazeaux  reporting  one  case  in  which  the  extravasation  was  so 
extensive  that  it  ploughed  up  the  abdominal  wall  of  the  right  side  to  the 
costal  margin.  Occasionally  the  rupture  occurs  in  the  wall  of  the 
vagina,  and  only  reaches  the  vulva  by  an  extension  of  the  accumulation, 
while  in  other  cases  the  hematoma  is  confined  to  the  vaginal  wall. 
Sometimes,  the  distention  becomes  so  great  that  the  skin  or  mucous 
membrane  gives  way  and  the  blood  clot  escapes.  If  the  hematocele  is 
the  result  of  rupture  of  an  artery,  the  hemorrhage  resulting  from  the 
breaking  down  of  the  skin  may  become  active,  even  after  the  clot  has 
been  in  situ  for  a  number  of  days.  In  small  accumulations  the  clot 
may  be  absorbed;  in  others,  where  the  pressure  of  the  integument  is 
very  great,  or  where  the  contusion  has  been  extensive  and  severe,  gan- 
grene may  result.  In  occasional  cases  the  clot  may  become  solidified, 
even  to  the  extent  of  calcification.  The  symptoms  of  pudendal  hemato- 
cele consist  of  swelling  of  the  labia,  with  |)ain  in  the  parts,  which,  even 
in  the  midst  of  the  pains  of  labour,  is  generally  sufficiently  severe  to 
attract  the  attention  of  the  patient.  The  tumour  increases  rapidly  in 
size  and  at  first  is  usually  without  any  change  of  colour  in  the  skin, 
but  later  becomes  pinkish  and  bluish,  and  finally,  when  absorption 
is  well  under  way,  it  becomes  brown  or  bronzed  in  appearance.  This 
tumour  is  generally  at  first  very  tense,  but  later,  as  absorption,  or  sup- 
puration takes  place,  becomes  softer  and  more  fluctuating.  Its  forma- 
tion may  be  attended  with  some  shock,  corresponding  in  degree  to 
the  severity  of  the  causative  injury  or  the  amount  of  the  extravasated 
blood.  The  rarity  of  this  complication  of  labour,  says  Sasonofl^ 
(Archives  de  gynecologie,  November,  1884),  will  be  appreciated  when 
it  is  remembered  that  Winckel  noted  only  one  case  out  of  1,600 
confinements;  Hecker,  two  cases  out  of  17,200;  Spiegelberg,  three  out 
of  3,000;  and  that,  at  the  St.  Petersburg  Maternity,  there  have  occurred 
only  eight  cases  out  of  19,396  labours.  Generally,  then,  it  may 
be  said  that  this  complication  occurs  but  once  in  2,375  labours.  The 
prognosis  of  these  cases,  so  far  as  life  is  concerned,  is  favourable,  and 
hematocele  is  rarely,  if  ever,  fatal  from  the  loss  of  blood,  unless  there 
is  secondary  rupture,  when  the  subcutaneous  extravasation  becomes 
converted  into  a  free  hemorrhage.  These  injuries,  however,  are  in  many 
instances  associated  with  enough  superficial  destruction  of  tissue  to 
serve  as  an  infection  air-iiim,  witli  the  rfwiilt  that  the  underlying  clot  is 


138 


A  TEXT-BOOK  OF  GYNECOLOGY 


yery  liable  in  the  course  of  the  next  few  days  to  become  converted  into 
a  culture  medium  for  the  propagation  of  pyogenic  bacteria.  As  a  com- 
plication of  labour,  pudendal  hematocele  is  looked  upon  by  both  Play- 
fair  and  Cazeaux  as  very  serious.  Tate  (loc.  cit.)  has  collected  cases  of 
pudendal  hematocele  occurring  as  a  complication  of  labour  as  follows: 


Cases. 

Fatal. 

Playfair  (collected  by  various  French  authors). . 
Scanzoni   

124 
15 
62 
22 
19 
50 

44 
1 

Deneaux  

22 

Barker 

3 

Blot 

5 

Winckel 

6 

Total 

292 

81 

It  must  be  remembered,  however,  that  in  explaining  the  mortality 
of  81  in  a  total  of  292  cases  from  an  accident  intrinsically  so  controlla- 
ble as  pudendal  hematocele,  an  important  percentage  of  these  cases 
occurred  before  the  inauguration  of  the  present  antiseptic  regime.  It 
is  true  that  of  these  cases,  but  three,  those  reported  by  Barker,  were 
recorded  as  having  died  from  sepsis;  but  this  fact  does  not  exclude  the 
extreme  possibility  that  an  important  number  of  the  remaining  deaths 
occurred  from  the  same  cause. 

The  treatment  should  vary  a  little  according  as  the  hematocele  is  the 
result  of  external  violence  or  of  parturition,  and  according  to  the  size 
of  the  clot.  If  external  violence  is  the  cause,  and  if  the  clot  is  large,  and 
has  developed,  or  is  developing,  with  rapidity,  there  is  strong  probabil- 
ity that  it  is  being  fed  by  a  severed  artery,  under  which  circumstances 
the  patient  should  be  anaesthetized  and  the  bleeding  points  found  and 
ligated.  If,  however,  the  clot  has  formed  slowly,  and  is  not  large,  it 
should  be  treated  with  rest  and  the  application  of  ice  bags.  If,  after 
a  few  days,  the  tumour  becomes  red  about  its  circumference  and  the 
pain,  of  a  pulsating  character,  shows  a  tendency  to  increase,  and  if  there 
is  some  elevation  of  temperature,  the  clot  may  be  considered  to  be 
the  seat  of  incipient  suppuration  and  should  be  freely  incised,  its  cav- 
ity thoroughly  cleansed,  first  with  the  hydrogen  peroxide,  and  next 
with  a  l-to-2,000  mercuric  bichloride  solution. 

If  a  hematocele  occurs  as  a  complication  of  labour,  rather  more 
chances  should  be  taken  to  secure  its  absorption;  as  a  free  incision  in 
the  presence  of  the  probably  contaminated  lochia  may  be  far  from 
an  innocent  procedure.  It  should  be  remembered  that  there  exists 
the  reciprocal  danger  of  liberating  into  the  vagina,  or,  at  least,  about 
its  orifice,  pathogenic  bacteria  that  have  developed  in  the  pus  of  a 
suppurating  hematocele.  A  pudendal  hematocele  in  a  parturient  case 
should,  therefore,  be  opened  only  in  the  presence  of  the  most  positive 
indications,  after  which  its  treatment  should  be  conducted  on  lines  of 
the  most  rigorous  and  persistent  antisepsis. 


INJURIES  OF   THE   EXTERNAL   GENITAL   ORGANS  139 

Injuries  to  the  external  genital  organs  due  to  parturition,  aside 
from  pudendal  hematocele  which  has  just  been  considered,  occur  in  (a) 
the  perineum  (see  Pelvic  Floor  and  its  Injuries),  and  (6)  the  vagina. 
Of  the  injuries  to  the  vagina,  the  chief  ones  are  rupture  and  fistulse. 

Injuries  of  the  Vagina. — Eupture  may  occur  at  any  place,  although 
it  is  more  common  in  the  posterior  than  in  the  anterior  wall.  Such 
lacerations  have  occurred  through  the  vault  of  the  vagina  into  Douglas's 
cul-de-sac  and  through  the  recto-vaginal  septum.  They  have  occurred 
also  in  the  fornices,  splitting  up  the  broad  ligament  and  causing  dan- 
gerous hemorrhage,  by  severing  the  important  blood  vessels  that  lie 
upon  either  side  of  the  vaginal  tract.  Wlien  these  lacerations  occur, 
they  should  be  immediately  cleansed,  and  the  usually  contused  and 
roughly  lacerated  margins  of  the  wound  pared  off  and  approximated 
by  interrupted  nonabsorbent  sutures.  Many  of  these  lacerations  pass 
without  recognition  and  heal  spontaneously  by  the  formation  of  irregu- 
lar cicatrices  which  narrow  the  vagina  in  an  irregular  way,  causing 
dyspareunia  and  other  distressing  symptoms. 

Enpture  of  the  vagina  is  to  be  looked  upon  as  a  tear  due  to  the 
joint  influence  of  an  expansive  force  and  to  the  inelasticity  of  the 
canal.  It  may  result  in  the  formation  of  a  fistula,  but  a  rupture  is  to  be 
distinguished  from  a  fistula  in  the  particular,  that  while  a  tear  is 
caused  as  already  indicated,  fistula  is  generally  the  result  of  prolonged 
pressure  and  subsequent  necrotic  changes. 

Fistulse. — A  fistula  is  an  unnatural  channel  that  leads  from  a  cuta- 
neous or  a  mucous  surface  to  another  free  surface,  or  that  terminates 
blindly  in  the  substance  of  an  organ  or  part.  The  edges  of  such  open- 
ings are  covered  with  epithelium.  The  forms  of  fistula  that  are  met 
with  in  the  female  genital  tract  are  urinary  and  fgecal. 

Urinary  Fistulce.  Fcecal  Fistulce. 

Urethro- vaginal.  Recto-perineal. 

Yesico-vaginal.  Eecto-vaginal. 

Vesico-uterine.  Entero-vaginal. 

Uretero- vaginal. 
Uretero-uterine. 

Urinary  Fistulse  (Urethro-vaginal,  Yesico-vaginal). — The  variety 
most  commonly  met  with  is  the  vesico-vaginal  (Fig.  58).  It  sometimes 
happens  that  a  fistula  exists  between  the  bladder  and  the  vagina,  and, 
at  the  same  time,  that  the  urethra  has  been  partially  or  totally  de- 
stroyed. A  vesico-vaginal  fistula  may  vary  very  much  in  size.  At 
times  it  is  so  large  that  the  mucous  membrane  of  the  bladder  prolapses 
through  it  and  the  bladder  is  almost  turned  inside  out.  The  mucous 
membrane  is  easily  recognised  by  its  bright-red  colour.  At  other  times 
the  fistula  is  only  large  enough  to  admit  a  small  probe.  The  nearer 
to  the  1iiii(;  at  which  the  fistula  was  caused,  the  larger  is  the  open- 
ing.     Tlic   oiicnitigs   Hint   ai'O   at    first   large   gradually   contract   and 


140 


A   TEXT-BOOK  OF   GYNECOLOGY 


close.  It  is  then  difficult  to  say  how  large  the  opening  may  have  been 
originally.  The  cicatrix  that  is  formed  is  generally  thin  and  firm. 
When  the  urine  discharges  freely  from  the  bladder  after  the  formation 
of  a  fistula,  contraction  of  the  bladder,  with  thickening  of  its  walls. 


Fig.  58. — "The  variety  most  commonly  met  with  is  the  vesico-vaginal." — Eeed  (p.  139). 

ensues.  The  urethra  may  be  contracted  on  account  of  its  inactivity. 
The  vagina  around  the  edges  of  a  fistula  is  sometimes  firmly  fixed  to 
the  bone.  In  this  way  the  edges  of  the  fistula  are  drawn  apart.  Vesico- 
uterine fistulcp  are  rare.  They  can  only  be  recognised  after  the  uterine 
canal  has  been  opened  up.  Ureter o-vaginal  fisttdce  are  situated  in  the 
fornix  vaginae.  They  are  small  and  admit  only  of  the  entrance  of 
the  point  of  a  sound.  They  open  at  the  point  of  a  small  papilla  or  else 
have  very  sharja  edges. 

The  etiology  of  urinary  fistulaB  in  general  must  take  into  account 
the  element  of  pressure,  the  duration  of  which,  rather  tban  the  in- 
tensity, determines  the  injury.  Sometimes  the  surgeon  produces  a 
fistulous  opening  for  the  relief  of  chronic  cystitis,  or  for  the  removal  of 
a  stone  from  the  bladder,  or  the  bladder  may  be  accidentally  wounded 
during  the  performance  of  the  operation  of  hysterectomy.  Ulcerations 
of  the  bladder  may  occasionally  produce  perforation  of  the  septum,  and 
are  sometimes  a  consequence  of  the  presence  of  a  vesical  calculus.  A 
pelvic  abscess  may  open  in  such  a  way  as  to  give  rise  to  a  urinary  fistula, 
which  may  be  induced  also  by  foreign  bodies,  such  as  the  long-contin- 
ued use  of  a  pessary  in  the  vagina.  Injury  received  during  labour  is 
generally  looked  upon  as  the  most  frequent  cause  of  these  fistulous  open- 
ings. Such  a  condition  may  be  produced  by  a  tear  through  the  septum, 
or,  as  is  most  commonly  the  case,  a  necrosis  is  produced  by  pressure  dur- 


INJURIES  OF  THE  EXTERNAL   GENITAL   ORGANS  141 

ing  tedious  delivery.  Whatever  may  cause  a  difficult  labour,  may,  there- 
fore cause  a  fistulous  oj^ening  between  the  urinary  and  the  genital  tracts. 
It  is  not  necessary  to  dwell  upon  these  conditions,  as  they  are  well 
known.  Cuts  that  will  give  rise  to  fistulous  openings  may  occasionally 
be  produced  by  the  use  of  instruments  in  accomplishing  delivery.  Such 
cuts  usually  occur  in  the  lower  part  of  the  vagina.  The  forceps  is 
no  doubt  more  frequently  blamed  for  the  production  of  fistulous 
openings  than  it  should  be.  It  is  generally  used  in  difficult  labours; 
that  is  to  say,  those  in  which  there  is  long-continued  pressure  on 
the  soft  parts.  We  may  conclude,  therefore,  that  the  fistulous  open- 
ings are  due  to  the  long-continued  pressure  in  such  cases  and  not 
to  the  use  of  the  forceps.  They  may  be  due  to  the  nonapplication 
of  the  forceps.  Fistulous  openings  have  been  produced,  sometimes, 
as  a  consequence  of  cuts  made  by  splinters  of  foetal  bones  during 
the  performance  of  the  operation  of  craniotomy.  Malignant  disease 
frequently  causes  fistulous  openings,  not  only  into  the  bladder,  but 
also  into  the  rectum.  Nothing  can  be  done  by  surgical  means  to  alle- 
viate the  sufferings  of  these  poor  unfortunates,  and  such  cases  need 
not  be  considered  here.  A  calculus  is  frequently  formed  in  the  vagina 
as  a  consequence  of  the  presence  of  a  vesico-vaginal  fistula. 

The  symptoms  of  urinary  fistulse  in  general  demand  careful  consid- 
eration. When  a  patient  complains  of  an  involuntary  flow  of  urine, 
an  examination  should  always  be  instituted,  to  ascertain  the  reason 
why  siich  an  abnormal  condition  exists.  After  labour,  the  patient  may 
be  discharging  the  urine  naturally,  or  she  may  be  unable  to  pass  it, 
and  it  may  be  retained  in  the  bladder,  and  yet,  within  a  few  days,  there 
may  be  an  involuntary  flow  of  urine  due  to  the  presence  of  a  vesico- 
vaginal or  one  of  the  other  forms  of  urinary  fistulse.  The  pressure  at  the 
time  of  labour  produces  the  necrosis,  and  the  formation  of  the  opening 
is  delayed  for  several  days  until  the  slough  separates.  If  the  opening 
is  caused  by  a  tear,  urine  will  fiow  at  once  per  vaginam.. 

The  symptoms  vary  according  to  the  situation  of  the  fistulous  open- 
ing. When  situated  high  up,  the  bladder  fills  up  to  the  level  of  the 
fistula,  if  the  patient  is  in  the  erect  posture,  and  there  is  no  leak  until 
the  urine  reaches  so  high  as  to  overflow.  When  there  is  a  urethro- 
vaginal fistula,  the  bladder  may  be  able  to  hold  the  urine,  and  yet  the 
urine  will  not  come  out  through  the  normal  opening.  The  patient's 
clothing  in  these  cases  is  not  kept  wet.  The  odour  produced  from 
the  urine  becomes  unpleasant  to  the  patient  and  friends;  the  skin  of 
the  adjacent  parts  becomes  excoriated,  red,  and  irritated.  Sterility  is 
usually  produced,  although  there  have  been  cases  of  conception  re- 
corded. The  patient  feels  disagreeable  to  herself  and  to  others.  The 
general  health  frequently  becomes  considerably  impaired,  and  the  pa- 
tient is  always  ready  to  submit  to  operation  if  any  promise  of  relief 
can  be  given. 

Tlie  tlia/ivosis  iinist  be  rrijidc  between  these  flstiila^  and  certain  con- 
ditions of  ilie  bbiddci'  llial    nllow  Ihf  e.sca])('  of  ni'ine.      One  of  these 


142  A  TEXT-BOOK  OF  GYNECOLOGY 

conditions  is  a  paralysis  of  the  sphincter  vesicae  muscle,  due,  fre- 
quently, to  difficult  labour,  and  rendering  the  patient  unable  to  hold 
her  water.  It  may  remain  in  the  bladder  while  the  patient  lies  in  the 
recumbent  posture  at  night,  but  when  she  rises  to  the  erect  pos- 
ture it  comes  away  and  wets  her  clothing.  The  irritated  appearance 
of  the  genitals,  and  the  characteristic  odour,  indicate  that  there  is 
a  fistula.  To  be  satisfied  of  this,  it  is  a  good  plan  to  inject  sterilized 
milk,  or  a  coloured  nonirritating  fluid,  into  the  bladder.  Any  fluid 
escaping  from  the  bladder  can  then  be  more  readily  detected  on  ac- 
count of  its  colour.  This  method  is  one  of  the  best  in  vogue.  Some- 
times the  opening  can  readily  be  detected  with  the  finger.  When  the 
milk  is  being  used,  it  is  better  to  have  the  patient  turned  on  her  left 
side  with  the  Sims  speculum  in  position.  All  discharge  must  be  wiped 
away  from  the  vagina  in  order  that  the  field  to  be  inspected  may  be  in 
a  cleanly  condition.  As  the  bladder  is  distended,  we  must  carefully 
watch  the  anterior  vaginal  wall  for  any  oozing  of  the  stained  fluid. 
If  no  fluid  comes  away,  we  must  infer  that  the  opening  is  below  the 
sphincter,  or  that  no  opening  exists.  If  no  special  leak  occurs  during 
the  act  of  micturition,  we  must  then  conclude  that  the  leakage  of  urine 
is  not  due  to  the  presence  of  a  urinary  fistula,  but  is  due  to  some  other 
cause. 

In  considering  the  prognosis,  it  is  well  to  bear  in  mind  that  sm'all 
fistulse  sometimes  heal  without  any  surgical  intervention.  Many  of  the 
small  fistulse,  however,  and  all  of  the  large  ones,  require  operative 
treatment.  The  prognosis  is  not  so  favourable  for  cases  in  which  the 
connective  tissue  of  the  urethro-vaginal  and  vesico-vaginal  fold  is 
bound  down  to  the  bony  parts  in  the  neighbourhood.  If  this  condition 
is  present,  it  is  difficult  to  approximate  the  edges  without  great  ten- 
sion being  placed  upon  the  stitches. 

Treatment. — Eecently  formed  fistulous  openings  have  a  tendency  to 
close.  This  tendency  is  one  of  the  difficulties  met  with  in  attempting 
to  keep  up  free  drainage  from  the  bladder  by  means  of  an  artificially 
produced  vesico-vaginal  fistula  for  the  treatment  of  chronic  cystitis. 
Such  fistulous  openings  will  often  close  if  they  are  kept  clean  and 
anointed  with  a  little  vaseline  or  zinc  ointment,  and  if  the  bladder  is 
kept  washed  with  boric  acid  or  sodium  biborate  (3J  to  Oj)  solution,  to 
remove  the  incrustations  that  are  liable  to  form  at  the  edges  of  the 
fistula.  Operations  on  such  cases  are  difficult.  We  must  be  able  to 
reach  the  fistulous  openings,  and  we  must  be  able,  when  we  have  reached 
them,  to  bring  the  edges  carefully  together  with  sutures.  There  are 
two  positions  in  which  the  field  of  operation  may  be  brought  into  view. 
One  is  the  position  on  the  left  side  with  the  Sims  speculum,  and  the 
other  position  is  that  in  which  the  patient  is  placed  on  the  abdomen 
with  the  knees  hanging  over  the  end  of  a  structure  raised  up  in  the 
centre  of  an  operating  table.  To  use  the  latter  position,  Eoss  proceeds 
as  follows:  The  head  of  the  patient  should  be  lower  than  the  buttocks, 
and  therefore  different-sized  boxes  should  be  used,  carefully  padded  and 


INJURIES   OP   THE  EXTERNAL   GENITAL   ORGANS  143 

covered  with  pillows,  placed  upon  the  operating  table,  unless  one  is 
fortunate  enough  to  obtain  the  use  of  a  Bozeman's  table.  The  patient's 
head  is  made  comfortable,  her  arms  are  allowed  to  hang  down  on  either 
side,  parts  under  the  chest  and  abdomen  are  carefully  padded,  a  pillow 
is  inserted  under  the  crests  of  the  ilium  where  they  impinge  upon  the 
newly  constructed  platform,  and  great  care  is  taken  to  see  that  the 
knees  do  not  touch  the  table  below.  If  the  knees  are  allowed  to  press 
for  any  considerable  time  on  the  table  while  the  patient  is  under  an 
anaesthetic,  sloughs  may  be  produced  that  will  be  very  tedious  to  heal. 
A  rubber  sheet  is  placed  in.  such  a  way  that  the  water  that  is  being 
used  in  a  constant  stream  from  the  "  douche  can  "  or  "  bag  "  is  con- 
ducted to  a  foot  bath  at  the  end  of  the  table.  An  assistant  then  stands 
on  one  side  of  the  patient  and  holds  the  Sims  speculum,  or  some  modi- 
fication of  the  same,  in  position  on  the  posterior  vaginal  wall.  The 
operator  may  use  the  German  water  speculum  for  this  purpose.  It  is 
not  easy  for  the  angesthetist  to  give  the  angesthetic  while  the  patient  is 
in  this  position  unless  the  pillows  are  properly  arranged. 

Sims  pared  the  edges  of  the  fistula  in  such  a  way  as  to  avoid  the 
mucous  membrane  of  the  bladder.  He  brought  together  the  edges 
of  the  fistula  with  silver  wire,  without  allowing  the  stitches  to  pene- 
trate the  mucous  membrane.  Other  operators  have  not  done  this,  but 
have  cut  directly  through,  paring  all  tissues  evenly,  and  bringing  the 
edges  evenly  together  with  sutures  passing  through  the  mucous  mem- 
brane, as  well  as  through  the  vesico-vaginal  tissues.  Others  use  the  flap- 
splitting  method  in  order  that  they  may  be  able  to  make  use  of  the 
larger  wound  surface  thus  produced  in  the  healing  process.  Any  of 
the  three  methods  will  answer  if  certain  important  details  are  carried 
out.  The  approximation  must  be  exact  and  thorough;  the  stitches  must 
be  inserted  far  enough  away  from  the  edges  to  enable  them  to  give 
the  proper  amount  of  support;  precautions  must  be  taken  to  prevent  any 
contamination  of  the  wound  by  urine,  or  other  septic  material,  and  heal- 
ing by  first  intention  must,  if  possible,  be  procured. 

Each  case  must  be  individually  considered.  If  the  rules  that  are 
well-known  to  govern  the  healing  process  in  this  locality  are  adhered  to, 
success  will  follow;  if  these  rules  are  not  adhered  to,  success  will  not 
follow  the  operation,  no  matter  which  operator's  method  is  em^Dloyed. 
In  every  ease  of  vesico-vaginal  fistula  it  is  advisable  to  examine  for 
vesical  calculus  before  closing  the  fistula. 

It  is  not  wise  to  operate  at  too  early  a  period  after  the  formation 
of  the  fistula.  The  tissues  must  be  allowed  to  contract  to  their  utmost 
extent  and  to  regain  their  natural  condition  after  the  softening  that 
is  produced  as  a  result  of  pregnancy  has  disappeared.  Unless  this  is 
done,  they  are  too  friable  and  too  easily  torn  to  stand  the  strain  of 
stitches.  It  is  not  wise  to  attempt  to  operate  for  at  least  eight  weeks 
after  con  fin  cm  out,  nor  is  it  wise  to  do  a  second  operation  until  at  least 
a  moritli  oc  six  vvccl<s  liavc  cliipscd  since  the  first  was  performed.  A 
preparatory  ii(';iinK;nt  lias  been  advocated  by  some  for  the  purpose 


144  A   TEXT-BOOK  OF   GYNECOLOGY 

of  loosening  cicatricial  bands.  This  may  be  necessary.  Incisions  can 
be  made  and  tissues  loosened,  and  these  incisions  allowed  to  unite 
before  any  fresh  ones  are  made.    We  may  thus  gain  considerable  room. 

Frequent  vaginal  injections  are  not  necessary  in  all  eases,  in  order 
to  bring  the  edges  into  good  condition.  Any  irritation  that  is  present 
in  the  vagina  may  be  relieved  by  the  use  of  pessaries  made  of  fifteen 
grains  of  oxide  of  zinc  to  a  hundred  and  twenty  grains  of  cacao  butter, 
introduced  into  the  vagina  once  or  twice  a  day.  It  is  wise  to  heal  up 
ulcerations  about  the  buttock. 

Sims's  Operation. — The  bowels  having  been  thoroughly  evacuated 
by  a  cathartic  and  the  rectum  having  been  washed  out  by  an  enema 
immediately  before  the  operation,  the  patient,  having  been  shaved  and 
sterilized,  is  placed  upon  a  table  on  her  left  side  in  the  Sims  position 
(Fig.  2).  The  Sims  duck-bill  speculum  is  introduced  into  the  vagina 
and  intrusted  to  an  assistant,  who  is  instructed  to  hold  it  with  consid- 
erable attention,  exerting  the  force  in  an  upward  and  forward  direction. 
The  fistula  will  then  be  brought  to  view.  It  should  at  this  point  be 
inspected  carefully  to  determine  its  natural  lines  and  the  consequent 
direction  in  which  the  lips  will  be  approximated.  Having  determined 
this  point,  the  margin  of  the  fistula  is  seized  with  a  volsella  or  long 
hemostatic  forceps  and  the  continuous  strip  of  cicatricial  tissue  is  cut 
away  from  the  margin  of  the  fistula  along  its  entire  circumference, 
care  being  taken  to  avoid  the  vesical  mucosa.  The  small  amount  of 
blood  that  oozes  from  this  surface  should  now  be  carefully  wiped  away 
and  the  surface  inspected.  If  at  any  point  the  surface  is  not  deemed 
broad  enough  for  the  purpose  of  approximation  and  union,  a  little 
more  tissue  may  be  removed.  Simon,  who  was  very  successful  in  deal- 
ing with  this  accident,  included  the  vesical  mucous  membrane  in  the 
denudation;  but  Emmet  avoided  doing  so  on  the  ground  that  it  caused 
unnecessary  and  often  embarrassing  hemorrhage.  He  alludes  to  a  case 
in  the  practice  of  Peaslee  in  which  the  patient  died  from  hemorrhage 
of  this  character.  In  some  cases  in  which  the  vaginal  wall  was  made 
too  thin,  it  was  the  practice  of  Sims,  Emmet,  Bozeman,  and  the  early 
operators  in  this  field,  to  carry  the  denudation  to  the  vaginal  surface; 
or,  if  this  was  impracticable,  to  split  the  margins  of  the  flap.  It  was 
in  this  incidental  practice  that  these  early  operators  gave  recognition 
to  an  important  principle  of  procedvire,  which  man}^  years  later  was 
published  by  Lawson  Tait  and  adopted  by  his  followers.  The  margins 
of  the  fistula  having  been  thus  incised,  a  short,  strong,  slightly  curved 
needle,  loaded  with  a  double  loop  of  silk  thread  and  carrying  silver  wire, 
is  passed  through  one  lip  of  the  fistula,  and  brought  over  and  out 
through  the  other  lip  at  a  directly  opposite  point.  One  after  another  of 
these  sutures  is  passed  at  intervals  of  from  an  eighth  to  three  sixteenths 
of  an  inch  apart.  When  the  silver  wires  are  all  in  situ,  the  margins  are 
again  washed  carefully  and  the  sutures,  one  after  another,  are  closed  by 
simply  bringing  the  opposite  ends  together  and  twisting  them.  Great 
care  should  be  exercised  in  this  manipulation,  as  by  overdoing  it  the 


INJURIES  OF  THE  EXTERNAL   GENITAL  ORGANS 


145 


entire  operation  may  be  easily  defeated.  It  is  important  to  cross  the 
wires  first  and  ascertain  exactly  the  point  at  which  they  will  cross. 
Each  end  should  be  bent  by  a  sharp  angle  at  that  point,  crossing  and 
twisting  thence  outward.  If  they  are  crossed  without  any  regard  to  this 
precaution,  the  twisting  will  extend  toward  the  field  of  operation 
and  toward  the  distal  layer  of  the  wall.  In  this  way  a  destructive 
tension  will  be  brought  to  bear  upon  the  tissues,  the  wire  will  cut  out 
before  union  is  completed,  and  the  objects  of  the  operation  will  be 
defeated.  Silkworm  gut  may  be  employed  as  a  suture  material, 
although  it  is  probable  that  if  the  technique  of  Sims  is  to  be  followed, 
it  would  be  better  to  follow  it  in  its  entirety.  The  operation  thus  con- 
cluded, the  vagina  is  again  thoroughly  irrigated  and  a  little  gauze  is 
inserted.  The  sigmoid  catheter  with  several  feet  of  small  drainage 
tubing  attached  is  inserted  into  the  urethra  and  the  patient  is  put 
to  bed. 

Ross's  Operation. — The  instruments  required  for  the  operation  are 
:as  follows: 


■Sims's  speculum,  or  some  modification  of 
Siras's,  sucli  as  Simon's,  Fritsch's,  the 
self-retaining,  or  the  German  water 
speculum. 

Retractors  or  spatulse. 

Three  or  four  single-toothed,  double- 
bladed  tenacula. 

Douche  can  and  tube. 

Pressure  forceps. 

Long-handled  dissecting  forceps. 

Several  other  long-handled  tissue  forceps. 

Small  bistouries,  or  a  set  of  Sims's  vesico- 
vaginal fistula  blades. 


Angular-curved  and  flat-curved  scissors. 

Small  sponges  or  wipes. 

Sponge  holder. 

Curved  needles,  short,  but  curved  almost 

into  an  oval  instead  of  into  a  circle, 

with  cutting  sides. 
Needle  holder. 
Silver  wire,  best  quality. 
Catgut. 
Silkworm  gut. 
Wire  twister. 
Blunt  hook. 
Large-sized  male  sound. 


In  a  good  light,  with  the  patient  in  a  position  on  the  face  and 
properly  placed,  the  operator  standing  up  to  his  work,  the  water  specu- 
lum holding  the  posterior  vaginal  wall  and  allowing  water  to  constantly 
trickle  over  the  fistulous  opening,  this  operation  is  rendered  an  easy 
one.  It  may  be  performed  without  an  ansesthetie  and  with  perfect 
success.  It  is  the  getting  at  the  part  that  is  the  most  difficult  portion 
of  the  operation.  After  the  parts  have  been  reached  by  sight  and  by 
touch  it  is  then  an  easy  matter  to  pass  the  sutures. 

Any  sponges  that  may  be  used  must  be  small.  If  a  current  of  water 
is  allowed  to  trickle  continuously,  it  is  scarcely  necessary  to  use  sponges. 
When  we  are  ready  to  pare  the  wound,  a  tenaculum  should  grasp  each 
side  of  the  fistulous  opening,  taking  in  all  the  structures.  The  tenacu- 
lum should  be  one  that  will  lock,  so  that  it  can  hang  in  position  with- 
out requiring  tbc  attention  of  a  band.  A  sound  is  passed  into  the  blad- 
der to  push  out  the  wall  during  the  paring  of  the  edges  of  the  fistula. 
Then,  either  a  knife  is  passed  directly  through  the  edges  of  the  wound, 
in  order  iliai  ;),  pofiion  may  })0  completely  pared  off,  or  a  pair  of 
11 


146  A  TEXT-BOOK  OP  GYNECOLOGY 

sharp-pointed  scissors  is  inserted  and  is  run  round  the  edges  as  the 
first  step  in  the  flap-splitting  process.  Some  operators  cut  down  on 
the  vaginal  side  away  from  the  edge  of  the  fistula,  as  far  as  halfway 
through  the  thickness  of  the  vesico-vaginal  septum,  and  then  turn  in 
toward  the  bladder  the  two  flaps  thus  removed,  so  that  the  bladder  con- 
tains a  small  portion  of  vaginal  mucous  membrane  lined  with  squamous 
epithelium.  The  outside  raw  surface  is  then  drawn  together  by  sutures. 
Hemorrhage  should  be  checked  by  means  of  the  hot  douche.  Any  large 
bleeding  points  found  should  be  compressed  with  pressure  forceps. 
This  should  be  done  before  the  edges  are  brought  together,  though  it 
is  not  wise  to  lose  much  time  if  general  oozing  continues,  as  the  pres- 
sure of  the  sutures  will  usually  stop  this.  The  greatest  amount  of 
oozing  usually  takes  place  from  the  congested  mucous  membrane  lining 
the  bladder.  The  edges  must  now  be  carefully  adapted  with  sutures. 
When  the  sutures  are  passed,  great  care  must  be  taken  not  to  include 
much,  if  any,  of  the  mucous  membrane  of  the  bladder.  A  blunt  hook 
is  used  to  make  counter  pressure  during  the  introduction  of  the  sutures. 
It  is  not  very  frequently  needed.  The  sutures  should  be  passed  close 
enough  together  to  afford  ample  support. 

If  silver  sutures  are  used,  iodoform  gauze  should  be  inserted  into  the 
vagina,  to  prevent  the  suture  ends  from  irritating  the  posterior  vaginal 
wall.  Care  must  be  taken,  in  removing  this  gauze,  not  to  use  any  force 
that  is  liable  to  disturb  the  stitches,  should  a  portion  of  it  become 
entangled  in  the  meshes  of  the  wire. 

With  reference  to  the  original  operation  of  Sims,  there  are  several 
points  that  are  ojDen  to  criticism,  notwithstanding  the  fact  that  he  and 
his  inmiediate  followers  achieved  great  success  in  their  operations  upon 
this  class  of  cases.  The  experience  of  the  profession,  however,  has 
demonstrated  that  a  modification  of  the  technique  will  result  in  greater 
facility  of  operation,  and  in  at  least  equally  satisfactory  results.  Thus 
the  Sims  operation  requires  the  presence  of  an  assistant  to  hold  the 
speculum.  When  the  perineum  is  retracted  and  the  atmospheric  pres- 
sure is  exercised  upon  the  anterior  vaginal  wall,  the  fistula  drops  inward 
and  forward — the  farthest  possible  distance  away  from  the  operator. 
It  is  necessary  for  him,  therefore,  to  employ  long-shanked  instruments 
to  conduct  his  operation.  The  method  of  denudation  is  one  which 
necessarily  sacrifices  a  greater  or  lesser  amount  of  tissue  from  a  locality 
where  too  much  tissue  has  already  been  destroyed.  In  the  event  of 
successive  operations  by  this  method,  the  hope  of  a  successful  issue  is 
ultimately  destroyed  by  the  sacrifice  of  the  septum.  Eeed  remembers 
to  have  seen  a  case  in  the  Eotunda  Hospital,  in  Dublin,  in  which 
the  entire  base  of  the  bladder  had  been  whittled  away  in  successive 
efforts  to  close  an  originally  large  fistula.  As  an  example  of  what  some 
operators  recognise  as  an  easier  and  equally  effective  technique  the 
following  is  given: 

Reed's  Operation. — The  patient  is  prepared  precisely  as  indicated 
in  the  preceding  paragraphs.     She  is  placed  on  the  table  on  her  back. 


INJURIES   OP   THE   EXTERNAL   GENITAL   ORGANS 


147 


with  her  knees  drawn  well  up,  and  retained  in  that  position.  Mechan- 
ical devices  are  better,  however,  as  injury  to  the  hip  joint  has  been  done 
by  the  unguarded  action  of  assistants  in  exercising  too  much  pressure 
upon  the  legs.  A  Jones's  self-retaining  speculum  is  now  inserted,  by 
which  means  the  fistula  is  brought  directly  into  view.  The  line  of 
closure  having  been  determined,  an  incision  is  made  outward  from 
either  angle,  extending 
through  the  mucous 
membrane  of  the  vagina. 
The  margin  of  the  fistula 
is  now  split,  either  by 
means  of  the  knife  or  a 
pair  of  sharp-pointed  scis- 
sors curved  on  the  flat, 
and  one  blade  inserted 
through  the  incision  al- 
ready made  beneath  the 
mucous  membrane,  and 
carried  around  to  the  in- 
cision in  the  opposite  an- 
gle (Fig.  59).  The  other 
lip  of  the  fistula  is  treat- 
ed in  the  same  way.  The 
mucous  membrane  of  the 
vagina  and  of  the  bladder 
are  by  this  means  sepa- 
rated into  two  flaps;  those 
in  the  bladder  can  be 
folded  inward  and  ap- 
proximated, while  those 
within  the  vagina  can  be 
folded  outward  and  simi- 
larly approximated.  A 
curved  needle  mounted 
on  a  handle  and  specially 
devised  for  the  purpose, 
is  now  inserted  just  be- 
neath the  vaginal  mu- 
cous membrane,  made  to 

dip  deeply  into  the  cellular  layer,  and  brought  out  just  beneath  the 
vesical  mucosa.  It  is  then  crossed  over  and  inserted  beneath  the 
vesical  mucosa;  dipped  deeply  into  the  cellular  layer,  and  brought 
out  just  beneath  the  vaginal  mucosa.  It  is  then  threaded  with 
silku'oirn  gnt  and  withdrawn.  Other  sutures  passed  in  a  similar 
way  at  intervals  of  less  than  a  qnarter  of  an  inch  (Fig.  60)  are 
then  drawn  together  and  tied.  In  this  way,  the  approximation 
surfaces  are  increased  in  area  (Fig.  Gl)  while  by  the  old  through-and- 


FiG.  59.- 


-"  The  margin  of  the  fistula  is  now  split. "- 
Eeed. 


148 


A   TEXT-BOOK   OF   GYNECOLOGY 


through  sutures  they  are  diminished  in  area  (Fig.  62).     The  sutures 
are  removed  on  the  eighth  or  tenth  day.     The  buried  suture   may 

be  employed  somewhat  after 
the  manner  introduced  by 
Martin,  of  Berlin.  After  the 
denudation  has  been  made, 
just  as  in  the  operation  by 
means  of  the  interrupted  su- 
ture, formalinized  catgut  is  in- 
serted so  as  to  include  all  of 
the  cellular  structure  between 
the  two  mucous  layers.  A  con- 
tinuous suture  is  employed  for 
this  purpose,  involving  the  cel- 
lular tissue,  but  not  passing 
through  either  mucous  layer 
(Fig.  63),  as  generally  tied, 
and  the  superficial  intermucous 
suture  is  then  adjusted.  The 
advantage  of  this  form  of  clos- 
ure is  that  the  approximation 
is  very  effective  and  no  trouble 
arises  from  the  removal  of 
sutures. 

After-treatment. — Some  op- 
erators do  not  use  the  semi- 
prone   position   and   the    self- 
but  this   treatment  is   the   best 


Fig.  60.- — "  Other  sutures  are  passed  in  a  similar 
way  at  intervals  of  less  than  a  quarter  of  an 
inch." — Eeed  (page  147). 


retaining   catheter  after   operation; 

that  can  be  pursued  and  is  adopted  by  many 

If  it  is  intended  to 
place  a  catheter  in  the 
bladder  the  best  form 
to  use  is  Skene's  modi- 
fication of  Bozeman's 
self  -  retaining  hard- 
rubber  catheter.  There 
is  another  form  of 
winged  soft  -  rubber 
catheter  that  can  be 
used.  The  urine  is 
then  collected  in  a 
vessel  placed  in  bed. 
The  catheter  should 
be  changed  every  day, 
as  the  salts  of  the 
urine  are  deposited  on  the  perforations,  and  in  this  way  the  instrument 
is  very  soon  blocked  up.    The  instrument  also  requires  cleansing,  but  it 


Fig. 


61. — "  In  this   way  the  approximation  surfaces  are  in- 
creased in  area." — Eeed  (page  147). 


INJURIES   OP   THE  EXTERNAL  GENITAL  ORGANS 


149 


^can  be  replaced  in  the  bladder  a  few  minutes  after  its  removal.  It  is 
better  to  have  two  catheters,  so  that  when  one  is  removed  for  the  pur- 
pose of  cleansing,  the  other  can  be  placed  in  position.  The  nurses  must 
be  vigilant,  and  immediately  report  any  plugging  of  the  catheter  to  the 
proper  authority.  Some  prefer  to 
use  the  catheter  for  two  or  three 
days  only,  and  then  to  have  the 
urine  drawn  every  three  hours. 
Tsokana,  of  Athens,  Greece,  re- 
ports, in  a  communication  to  the 
editor,  that  he  closes  the  fistula 
with  interrupted  silkworm  gut  su- 
tures, tied  by  a  single  knot  with 
an  extra  whirl,  and  permits  his 
patients  to  get  up  and  go  about 
shortly  after  the  operation  is  com- 
pleted. His  results  are  satisfactory,  as  he  claims  that  the  upright  pos- 
ture favours  the  natural  drainage  of  the  bladder  and  the  retention  of 
the  parts  in  a  state  of  approximation. 

The  after-dangers  of  the  operation  are  irritation  and  inflammation 
of,  and  hemorrhage  into,  the  bladder.     When  blood  clots  collect  they 


Fig.  62. — •'  By  the  old  tlirough-and-through 
sutures  the  approximation  surfaces  are  di- 
minished in  area." — Keed. 


Fig.  iy.i. — "  A  continuous  suture  is  employed  for  this  purpose,  involving  tlie  cellular  tissue, 
but  not  passing  through  either  mucous  layer." — Reed. 

arc  1  roidjlesonif;.  If  the  h(;niorr}iage  is  severe,  the  fistulous  opening 
must  Ijo  n'0|iciicfl.  ''I'his  should  not  be  necessary  if  ]')roper  attention 
to  (Ifiiiils   is  given   at  tlie   iinic;   of  ojxiration.      It  is   always  possible 


150  A  TEXT-BOOK  OF  GYNECOLOGY 

that  a  hemorrhage  ma}'  occur,  subsequently  to  operation,  in  a  patient 
jDrone  to  bleed,  but  all  excessive  hemorrhage  should  be  checked  at 
the  time  of  operation  before  the  stitches  have  been  finally  tied.  If 
secondary  hemorrhage  occurs  from  the  third  to  the  fifth  day,  a  vaginal 
tampon  may  relieve  it.  The  ureter  has  been  caught  in  a  stitch  on  more 
than  one  occasion.  If  the  jDatient  suffers  from  intense  pain  in  the 
neighbourhood  of  the  kidney  after  the  performance  of  this  operation, 
one  should  suspect  that  some  such  unfortunate  occurrence  has  taken 
place.  Symptoms  of  uremic  poisoning  may  set  in  as  a  consequence  of 
this  accident.  The  sutures  are  usually  removed  from  the  seventh  to  the 
tenth  day.  Great  care  must  be  taken  in  removing  these  sutures.  If 
silver  wire  is  used,  the  portion  of  the  loop  away  from  the  knot  should 
be  bent  outward,  so  that  the  loop  then  has  about  the  curve  of  one  of  the 
needles  used  in  placing  the  sutures.  Counter  pressure  should  be  placed 
over  the  parts  while  the  stitches  are  being  withdrawn.  Sutures  must  be 
counted  and  must  be  all  removed,  because  a  loop  of  wire  left  behind 
may  afterward  become  the  nucleus  of  a  vesical  calculus.  The  catheters 
placed  in  the  bladder  should  be  kept  in  situ,  except  when  they  are  re- 
moved for  cleansing  purposes,  until  the  operator  feels  satisfied  that 
the  patient  can  pass  water  voluntarily  without  breaking  down  the 
wound.  This  will  depend,  to  a  great  extent,  upon  the  appearance  of 
the  wound.  In  some  cases,  it  is  possible  to  let  the  patient  void  urine 
earlier  than  in  others.  The  smaller  the  fistulous  opening,  the  earlier 
the  patient  may  be  allowed  to  void  urine;  the  larger  the  opening,  the 
longer  this  act  should  be  delayed.  If  there  is  no  great  amount  of  vis- 
ceral irritation,  Eoss  leaves  the  self-retaining  catheter  in  situ  until 
after  the  stitches  have  been  removed,  and  keeps  the  patient  turned  on 
her  face  for  at  least  a  week  after  the  performance  of  the  operation. 

When  the  operation  has  not  been  an  entire  success,  a  second,  a 
third,  or  even  a  fourth  must  be  performed.  At  each  operation  a 
portion  of  the  fistulous  opening  closes  and  the  fistula  becomes  smaller. 
One  must  not  be  discouraged.  Each  operation  should  bring  us  nearer 
the  long-looked-for  goal. 

It  sometimes  happens  after  these  operations  that,  when  the  fistulous 
opening  is  closed,  the  patient  continues  to  lose  urine  involuntarily  and 
does  not  believe  in  her  recovery.  In  such  cases  there  has  been  a  loss 
of  tone  in  the  sphincter  vesicae  muscle,  but  in  others  the  parts  gradually 
regain  their  tone. 

Atresia  of  the  "Upper  Part  of  the  Urethra  is  sometimes  found  in  cases 
in  which  a  vesico-vaginal  fistula  exists.  It  will  then  be  necessary  to 
make  a  new  opening,  and  to  keep  it  open  by  the  use  of  sounds,  unless  the 
operator  feels  disposed  to  cut  out  a  portion  of  the  urethra  and  unite 
the  neck  of  the  bladder  to  the  portion  of  the  urethra  below  the  excision. 
If  atresia  exists  between  a  urethral  fistula  below  and  a  vesico-vaginal 
fistula  above,  the  readiest  way  to  deal  with  it  is  to  thoroughly  loosen  up 
the  tissues  and  bring  the  upper  edge  of  the  vesical  fistula  down  to  the 
outer  edge  of  the  urethral  fistula.     To  unite  such  a  fistula,  however,  a 


INJURIES  OF   THE   EXTERNAL   GENITAL   ORGANS 


151 


combination  of  the  transverse  and  longitudinal  operation  may  be  done. 
A  transverse  incision  may  be  made  by  making  an  artificial  vesico-vagi- 
nal  fistula  just  above  the  neck  of  the  bladder.  The  upper  edge  of  this 
can  then  be  stitched  to  the  lower  edge  of  the  urethral  fistula,  and,  after 
healing  has  taken  place,  the  edges  of  the  original  vesico-vaginal  fistula 
can  be  closed  by  stitches  placed  so  as  to  bring  the  edges  together  from 
side  to  side,  leaving  a  longitudinal  scar. 

TJretero-vaginal  Fistula. — A  fistula  may  readily  be  formed  between 
the  ureter  and  the  utei-us,  or  between  the  ureter  and  the  vagina.  Such 
fistulEe  are  fortunately  rarely  met  with.  They  are  very  difficult  to  deal 
with  and  at  times  somewhat  difficult  to  discover.  These  fistulas  can 
be  most  readily  discovered  by  means  of  a  probe.  If  the  probe  passes 
on  farther  than  the  confines  of  the  bladder  would  indicate,  it  must 
be  disappearing  into  the  ureter  toward  the  kidney  on  that  side.  We 
can  make  out  the  pervi- 
ousness  of  the  lower  por- 
tion of  the  ureter  by  in- 
troducing a  probe  in  the 
■other  direction  toward 
the  bladder. 

Treatment.  —  Ne- 
phrectomy may  be  con- 
sidered but  should  only  be 
carried  out  as  a  last  re- 
source. If  the  fistula  can 
1)6  closed  by  a  direct 
method  of  operation,  this 
should  be  carried  out.  If 
it  can  not  be  closed,  we 
must  then  contemplate 
implantation  of  the  ureter 
in  the  bladder. 

To  effect  closure  of  the 
fistula,  an  incision  may  be 
made  down  over  the  ureter 
and  a  catheter  passed 
into  the  bladder,  and  out 
through  an  artificial  open- 
ing made  in  the  bladder 
wall  just  below  the  ure- 
teral fistula.  The  cathe- 
ter can  then  be  carried  on 


Fio.  64.— "Kecto-vaginal  listula."— Mayo  Kubsun  (p.  152). 


up  into  the  ureter  and  the  tissues  around  closed  by  silver- wire  sutures. 
Another  catheter  may  be  placed  in  the  bladder  alongside  of  this  one  in 
ordf'r  that  it  may  be  kept  (mipty.  The  flap-splitting  method  may  be  here 
j)[)|)li('fl,  as  in  v(!sico-vagina]  fistula  operations.  (For  the  operation  of 
iin|il;iiit;itio)i  of  the  iirdcr  ill  llic  l)la(ldcr  see  Uretcro-cystostomy.) 


152 


A  TEXT-BOOK   OF   GYNECOLOGY 


Recto-vaginal  Fistula. — Eecto-vaginal  fistvila  is  by  far  the  most  fre- 
quent of  the  fistulge  between  the  intestinal  and  vaginal  tracts,  and  may 
occur  at  any  part  of  the  posterior  vaginal  wall  (Fig.  64).  It  is  a  pecul- 
iarly distressing  ailment,  not  only  because  of  faeces  escaping  by  the 
vagina,  but  from  the  fact  that  intestinal  gases  pass  into  the  vagina  and 
escape  with  an  audible  bubbling  or  hissing  noise;  and  the  odour  being 
perceptible  to  the  sufferer,  she  broods  over  her  condition,  secludes  her- 
self from  society,  and  usually  passes  a  miserable  existence,  which  may 
end  in  melancholia. 

Causes. — Cancer,  syphilis  (see  Malignant  Neoplasms  of  the  Va- 
gina; also  Syphilis),  and  injury  are  the  usual  causes.  Pyosalpinx 
and  other  inflammatory  diseases  of  the  appendages  not  infrequently 
cause  fistula?,  but  these  are  usually  rectal  or  vaginal,  seldom  recto- 
vaginal. 

Fistula  from  Traumatism. — Eecto-vaginal  fistiila  may  occur  from 
the  ulceration  induced  by  the  long-continued  presence  of  a  pessary, 

from  the  presence  of  some 
"H  foreign  body  in  the  vagina  or 
rectum,  or  from  a  stab  wound 
accidental  or  intentional.  In 
these  cases,  the  fistula  usually 
heals  on  removal  of  the  cause, 
together  with  careful  attention 
to  the  wound  by  mild  antisep- 
tic douches  and  gauze  packing. 
Sometimes,  stretching  the 
sphincter  so  as  to  temporarily 
paralyze  it  gives  rest  to  the 
parts  and  assists  the  healing 
process. 

Injuries  occurring  in  child- 
birth leading  to  recto-vaginal 
fistula  are  not  so  infrequent  as 
modern  obstetric  treatment 
might  lead  one  to  suppose. 
They  not  infrequently  follow 
complete  rupture  of  the  peri- 
neum, where  the  rent  has 
])assed  well  up  the  recto-vag- 
inal septum,  and  where  the 
primary  operation  has  led  to 
healing  of  the  perineum  and 
perhaps  of  the  sphincter,  but 
where  there  has  been  a  failure 
in  union  of  the  rectal  wound. 
These  fistulae  may  occur  at  any  part  on  the  posterior  wall  of  the  rec- 
tum, from  just  within  the  sphincter  up  to  the  highest  point  the  finger 


Fig.  65. — "  Lay  the  whole  fistula  open  by  cutting 
through  the  tissues  intervening  between  it 
and  the  surface." — Mayo  Eobson  (page  154). 


INJURIES  OF   THE  EXTERNAL   GENITAL   ORGANS 


153 


can  reach,  and  may  vary  in  size  from  an  opening  admitting  a  Xo.  1 
catheter  to  a  slit  admitting  one,  two,  or  three  fingers. 

They  may  also  follow  on  sloughing  caused  by  pressure  from  delayed 
delivery,  but  from  this  cause  recto-vaginal  is  much  less  common  than 
vesico-vaginal  fistula. 

Small  fistulse  will  occasionally  heal  spontaneously;  others  require 
surgical  intervention.  If  the  fistula  is  situated  high  up  in  the  vaginal 
canal  and  fails  to  close 
under  cleanliness  and 
general  attention  to  the 
bowels,  a  plastic  operation 
will  be  advisable. 

The  bowels  should  be 
well  cleared  by  aperients 
given  for  three  or  four 
days  before  operation, 
and  during  this  time  the 
vagina  should  be  douched 
night  and  morning  with 
some  nonpoisonous  anti- 
septic solution,  such  as 
salufer  or  izal. 

Mayo  Robson's  Opera- 
tion.— With  the  patient 
in  the  lithotrity  position, 
or  on  the  left  side,  and 
the  perineum  drawn  back 
by  a  retractor,  so  as  to  ex- 
pose the  fistula,  the  edges 
of  the  opening  are  pared 
by  a  narrow  sharp  knife 
or  by  means  of  small 
curved  scissors.  The  rec- 
to-vaginal septum  is  then 
split  by  a  blunt  dissector 
for  a  quarter  or  half  an 
inch  round  the  fistula,  so 

as  to  make  a  broad  raw  surface  without  material  loss  of  tissue,  and  so 
as  to  be  able  to  bring  together  the  rectal  part  and  the  vaginal  part  by 
separate  sutures. 

Catgut  sutures  are  first  applied  to  the  rectal  edge  of  the  fistula  by 
means  of  a  rectangular  cleft-palate  needle,  the  sutures  taking  up  the 
submucous  tissue  close  to,  but  not  including,  the  mucous  membrane, 
and  being  placed  sufficiently  close  to  occlude  the  rectal  opening.  These 
sutures,  being  applied  from  the  vaginal  surface,  are  tied,  cut  ofi:  short, 
and  buried  by  the  next  row  of  sutures,  which  may  be  of  chromicized 
catgut  or  of  silk  f)i'  silkworm  gut.     If  catgut  is  employed,  the  stitches 


Fig.  66. — "Sutures  are  inserted  in  the  margins  of  the 
vaginal  mucous  membrane  and  in  the  margins  of 
the  rectal  mucous  membrane."  —  Mayo  Kobson 
(page  154j. 


154 


A  TEXT-BOOK  OF   GYNECOLOGY 


may  be  buried;  if  silk  or  silkworm  gut  is  used,  the  sutures  must  be 
tied  on  the  vaginal  surface  and  removed  in  about  ten  days.  If  the 
vagina  is  contracted,  it  may  be  found  easier  to  repair  the  rectal  edges 
of  the  fistulas  from  the  bowel  surface,  using  a  Sims  speculum  through 
the  well-stretched  anus. 

After  operation  the  bowels  need  not  be  disturbed  for  a  week,  and 
then  an  olive-oil  injection  will,  as  a  rule,  answer  all  requirements. 

A  boric  acid  or  izal  vaginal  douche  should  be  used  night  and  morn- 
ing. The  employment  of  a  catheter  is,  as  a  rule,  neither  necessary  nor 
advisable.  The  patient  may  be  allowed  to  use  the  sofa  at  the  end  of  a 
fortnight. 

If  the  fistula  is  fairly  low,  say  within  an  inch  of  the  anus,  Mayo 
Eobson  finds  it  best  to  lay  the  whole  fistula  open  by  cutting  through  the 
tissues  (including  the  perineum  or  its  remains)  intervening  between 
it  and  the  surface  (Fig.  65).  This  he  does  by  one  sweep  of  a  probe- 
pointed  bistoury  or  by 
means  of  scissors,  the  va- 
gina being  thus  made 
continuous  with  the  rec- 
tum by  a  slit  instead  of  a 
fistula.  The  assistants  or 
nurses,  standing  one  on 
each  side,  place  a  hand 
on  the  skin  over  each 
tuber  ischii  and  retract 
gently,  converting  the  H- 
shaped  gap  into  a  trans- 
verse wound,  as  shown  in 
the  illustration;  pointed 
scissors  are  then  employed 
to  open  up  the  recto- 
vaginal septum  so  as  to 
convert  the  narrow  edge 
into  a  raw  surface;  slits 
are  then  made  on  each 
side  straight  forward  for 
about  an  inch,  as  in 
Tait's  operation  for  peri- 
neorrhaphy. The  angles 
being  drawn  forward  by 
catch  forceps,  chromi- 
cized  catgut  sutures  are 
inserted  in  the  margins  of 
the  vaginal  mucous  mem- 
brane, so  as  to  approximate  them  and  thus  form  the  vaginal  floor  by 
closing  the  V-shaped  slit;  and  in  the  same  way  chromicized  catgut 
sutures  are  inserted  in  the  margins  of  the  rectal  mucous  membrane,  so 


Fig.  67. — "  We  now  have  a  large  rectangular  raw  sur- 
face."— Mato  Eobson  (page  155). 


INJURIES  OF   THE   EXTERNAL   GENITAL   ORGANS  I55 

as  to  form  the  anterior  rectal  wall  by  closing  the  V-shaped  slit  in  the 
rectum  (Fig.  66);  these  sutures  are  cut  off  short.  We  now  have  a  large 
rectangular  raw  surface,  which  can  be  rapidly  closed  by  four  or  six 
silkworm-gut  sutures  entering  on  one  side  at  the  skin  margin,  and 
emerging  on  the  other  at  the  same  spot  as  in  the  well-known  and 
extremely  valuable  j^erineorrhaphy  operation  referred  to  (Fig.  67). 

Before  drawing  tight  the  last  series  of  sutures,  the  wound  is  bathed 
with  a  l-in-2,000  solution  of  perchloride  of  mercury.  ISTo  vessels  are 
ligatured.  When  the  final  sutures  are  tied  the  parts  look  perfectly  nor- 
mal and  no  raw  surface  can  be  seen.  The  bowels  are  moved  daily  after 
the  second  day  by  a  plain  water  enema,  and  the  vagina  is  washed  out 
daily  with  boric  lotion. 

ISTo  catheter  is  employed  if  it  can  be  avoided,  and,  as  a  rule,  its  use 
is  not  necessary. 

The  parts  are  dressed  with  iodoform  gauze,  over  which  wool  and  a 
T-bandage  are  applied.  The  sutures  are  removed  about  the  tenth  day 
and  the  patient  is  allowed  to  be  up  abou.t  the  fourteenth. 

Mayo  Eobson  says  that  he  can  with  the  utmost  confidence  recom- 
mend the  operation  as  a  most  satisfactory  and  expeditious  method  of 
treating  the  class  of  cases  under  consideration. 


CHAPTEE    XV 
INJURIES   OF   THE   EXTERNAL   GENITAL   ORGANS   (Continued) 

Rape — Objective  evidences:  A.  Local  conditions;  laceration  of  the  hymen,  vulva, 
hemorrhage,  evidence  of  recent  injury,  venereal  infection,  laceration  of  the 
vagina,  etc. ,  pregnancy ;  B.  Injuries  on  other  parts;  0.  Condition  of  clothing — 
Schedule  for  examination — Indecent  assault — Prolapse — Injuries  to  the  peri- 
neum and  vagina — Uterus. 

Rape. — Medico-legal  questions  in  relation  to  the  female  generative 
organs  chiefly  have  reference  to — 

1.  Pregnanes. 

2.  Parturition. 

3.  Sterility. 

4.  Venereal  disease. 

5.  Eape. 

6.  Indecent  assault. 

7.  Damage  claims  after  injury. 

8.  Malpractice  suits. 

Rape  is  defined  as  the  carnal  knowledge  of  a  female  without  or 
against  her  consent.  In  most  courts  vulvar,  not  vaginal,  penetration 
has  to  be  proved,  a  circumstance  very  disadvantageous  to  the  defence. 

In  cases  of  rape,  the  gynecological  specialist  is  rarely  the  first  to 
examine  the  victim,  who  has  usually  j)assed  through  the  hands  of  a 
police  surgeon  or  the  family  physician,  or  both.  If  a  gynecologist  is  con- 
sulted at  all,  it  is  usually  when  the  case  comes  into  court,  or  at  a  time 
when  the  characteristic  appearances  may  no  longer  be  present.  It  would 
be  greatly  in  the  interests  of  justice  to  have  a  regulation  enforcing  the 
co-operation  of  an  experienced  gynecologist  at  the  very  outset  in  every 
case.  The  significance  even  of  the  typical  lesions  is  by  no  means  easy 
to  estimate,  and  the  examinations,  especially  in  the  case  of  young  chil- 
dren, often  present  unusual  difficulty. 

The  objective  evidences  of  rape  are:  (a)  Local  injuries  to  the  geni- 
tals; (b)  injuries  elsewhere,  due  to  a  struggle,  or  possibly  to  sadism;  (c) 
signs  of  seminal  or  blood  stains  on  the  clothing,  tearing,  etc.  As  the 
subjective  evidence  mainly  rests  on  the  uncorroborated  testimony  of 
the  victim,  the  medical  examination  should  include  matters  which 
indirectly  corroborate  or  contradict  her  statements.  There  is  no 
crime  which  becomes  oftener  the  subject  of  groundless  charges  made 
156 


INJURIES  OF   THE   EXTERNAL   GENITAL   ORGANS  157 

for  purposes  of  blackmail  or  revenge.  We  will  consider  here  those 
points  which  call  specially  for  observation  from  the  gynecological  point 
of  view. 

A.  Local  Conditions. — These  are  only  characteristic  in  the  case  of 
virgins  or  where  unusual  force  has  been  exerted.  The  most  important 
are:  (1)  Laceration  of  the  hymen,  (2)  contusions  or  abrasions  of  the 
vulva,  (3)  hemorrhage,  (4)  evidence  of  recent  injury,  (5)  venereal 
infection  (gonorrhoea  or  SA^philis),  (6)  in  rare  cases,  lacerations  of  the 
vagina,  perineum,  rectum,  or  bladder  may  result  where  there  is  great 
disproportion  between  the  male  and  female  organs,  (7)  ^^regnancy 
may  also  occur. 

1.  Laceration  of  the  Hymen. — The  23rincipal  source  of  error  lies  in 
mistaking  for  lacerations  congenital  notches  or  defects.  The  appear- 
ance and  variety  of  these  are  well  depicted  in  photographs  in  E.  V. 
Hofmann's  Hand  Atlas  of  Legal  Medicine. 

The  variety  of  forms  which  these  conditions  may  assume  is  remark- 
able, and  the  general  profession  is  very  little  informed  about  them. 
The  most  important  form  is  the  fringed  or  serrated  hymen.  On  the 
one  hand,  one  of  these  conditions  may  give  the  impression  of  lacera- 
tion, and  on  the  other  it  is  often  evident  that  intromission  could 
take  place  without  rupturing  it.  There  is  also  the  danger  of  con- 
fusing ulcers  with  lacerations,  or  of  mistaking  old  lacerations  for 
recent  ones.  The  examination  should  be  made  most  carefully  with 
the  aid  of  an  assistant  and  in  a  good  light,  the  finger  being  passed 
round  behind  the  hymen  so  as  to  bring  it  into  relief.  Whitish 
scars  denote  lesions  previously  existing.  Granulating  wounds  and 
erosions  show  that  the  injuries  have  existed  several  days,  and  prob- 
ably a  week,  if  they  are  in  process  of  healing.  The  recent  defloration  of 
the  virgin  hymen  is  usually  accompanied  with  a  considerable  amount  of 
swelling,  redness,  and  pain.  Intromission  and  ejaculation  may,  how- 
ever, occur  without  rupture  of  the  hymen,  and,  owing  to  the  increased 
frequency  of  local  gynecological  treatment  in  young  unmarried  women, 
the  hymen  is  liable  to  have  been  previously  interfered  with.  A  ty]3ical 
ruptured  hymen  is  the  exception  rather  than  the  rule  in  most  cases  of 
rape. 

Full  objective  proof  is  only  forthcoming  in  a  small  proportion  of  all 
cases.  The  relative  proportion  of  the  genital  organs  in  the  victim  and 
the  accused  must  be  considered  in  order  to  give  a  definite  answer  in 
individual  cases. 

During  the  healing  stage  there  is  little  that  is  characteristic  in  the 
lesions. 

2.  Vulva. — The  contusions  about  the  vulva  should  be  associated 
with  ecchymosis  and  persist  for  a  week  or  ten  days. 

3.  Hemorrhage.— The  preservation  of  blood-stained  undergarments, 
etc.,  is  more  important.  Their  destruction,  or  washing  by  the  victim's 
family,  may  destroy  an  important  proof. 

4.  Jf  analoitiical  evidev.re  of  recent  injury  of  the  genitals  is  discov- 


158  A  TEXT-BOOK  OP   GYNECOLOGY 

ered,  it  will  usually  be  accepted  as  positive  proof  of  penetration.     Ab- 
sence of  anatomical  evidence  does  not,  however,  exclude  penetration. 

5.  Venereal  Infection. — The  presence  of  acute  gonorrliceal  discharge 
in  the  victim  makes  it  most  important  to  see  if  that  condition  exists  in 
the  accused.  The  diagnosis  should  always  be  confirmed  by  bacteriologic 
methods. 

It  is  much  less  easy  to  recognise  gonococci  in  the  female  than  in 
the  male  secretions,  owing  to  the  constant  presence  of  other  diplococci. 
Examinations  of  stains  upon  linen,  etc.,  for  gonococci  rarely  give 
trustworthy  results,  owing  to  the  numerous  sources  of  possible  error. 

After  a  first  coitus  a  slight  discharge  may  persist  for  a  few  days, 
and  want  of  cleanliness  may  in  itself  cause  a  discharge.  Eepeated  visits 
will  be  necessary  in  order  to  observe  the  course  of  the  case. 

Syphilis. — Hard  and  soft  chancres  are  occasionally  met  with  in 
connection  with  rape.  The  most  important  point  here  is  a  careful  in- 
vestigation of  the  date  of  onset  as  compared  with  the  date  of  the 
assault,  and  the  exclusion  of  lesions  elsewhere.  Eepeated  visits  are 
usually  necessary.  It  must  also  be  shown  that  the  accused  was  in  a 
condition  to  communicate  the  disease. 

6.  Severe  injuries,  such  as  rupture  or  laceration  of  the  vagina,  rectum, 
Madder,  or  perineum,  are  rare,  and  occasionally  they  are  fatal.  They 
are  most  liable  to  occur  when  a  number  of  men  violate  the  same  victim 
in  succession.  In  the  Oriental  child-marriage  such  injuries  are  fairly 
frequent. 

7.  Pregnancy. — The  correspondence  of  conception  with  the  time  of 
the  alleged  coitus  is  naturally  the  chief  point  to  establish. 

B.  Injuries  on  other  parts  should  be  carefully  searched  for,  espe- 
cially finger  prints,  scratches  and  bruises  of  the  abdomen,  pubes,  and 
thighs,  as  well  as  of  the  chest,  limbs,  and  face,  with  or  without  tearing 
of  the  clothing.  The  absence  of  these  tends  to  throw  doubt  upon  the 
allegations  of  rape,  unless  there  was  more  than  one  assailant,  or  the 
iise  of  narcotics,  intoxicants,  or  auEesthetics  is  alleged.  The  vexed  ques- 
tion of  the  possibility  of  rape  during  natural  sleep  has  little  practical 
bearing  upon  the  ordinary  class  of  cases.  Surprise  and  terror  may,  of 
course,  lessen  the  power  of  resistance.  Conditions  suggestive  of  sadism 
should  lead  to  a  very  careful  examination  into  the  mental  state  of  the 
accused. 

C.  Condition  of  the  Clothing,  etc. — Seminal  stains. — Besides  ex- 
amining the  clothing  for  signs  of  tearing,  any  stains  looking  like  semen 
or  blood  should  be  carefully  preserved  and  submitted  to  expert  examina- 
tion. The  well-known  straight  outlined  stifi^ening  of  the  stains  is  strik- 
ing. The  skin  of  the  abdomen  and  thigh  should  be  searched  for  tracea 
of  the  seminal  crust.  In  the  case  of  seminal  stains  the  Florence  reac- 
tion is  invaluable  as  a  prompt  preliminary  test.  A  drop  of  the  Florence 
solution  (composed  of  iodine,  2.5  parts;  potassium  iodide,  1.5  parts;  and 
water,  30  parts)  is  brought  into  contact  with  moistened  filaments 
from  fabrics  containing  semen  observed  beneath  the  microscope.     An 


INJURIES  OP  THE   EXTERNAL   GENITAL   ORGANS  159 

abundant  formation  of  fine  brown  needle-shaped  crystals  instantly  oc- 
curs. The  sensitiveness  is  decidedly  lessened  in  the  presence  of  urine, 
and  is  greater  in  cold  than  warm  solutions.  If  positive  results  are  thus 
obtained,  spermatozoa  should  be  searched  for  cautiously  by  moistening 
the  fabric  by  imbibition,  scraping  the  surface,  and  dissociating  the 
fibres.  The  best  results  are  obtained  by  making  a  culture  film  or  cover- 
glass  preparation  and  staining  with  the  eosin  and  methyl  green,  which 
gives  a  double  staining  of  the  head  of  the  spermatozoa.  The  specimen 
may  then  be  mounted  in  balsam  and  examined  under  a  one-twelfth-inch 
immersion  lens.  Unstained  specimens  examined  with  the  ordinary 
dry  lenses  are  much  less  characteristic. 

Spermatozoa  are  less  numerous  in  old  stains,  but  age  does  not  impair 
the  Florence  reaction.  To  preserve  suspicious  stains,  cut  out  the  sus- 
pected portion  of  the  material  and  jolace  it  between  flat  pieces  of  card- 
board during  transmission  to  the  laboratory.  The  fallacies  of  the 
Florence  reaction  as  a  final  test  are  that  lecithin  and  certain  decompo- 
sition products  give  similar  precipitates,  but  this  in  no  wise  impairs  its 
utility  as  a  preliminary  test.  Failure  to  give  the  reaction  does  not  prove 
the  stain  to  be  nonseminal,  but  makes  it  unlikely  that  positive  micro- 
scopic results  will  be  obtained. 

The  possibility  of  azoospermia  must  be  borne  in  mind. 

Stains  from  vaginal  or  nasal  mucus  or  pus  can  sometimes  be  recog- 
nised microscopically  by  the  cellular  element. 

Local  lesions  produced  during  rape  are,  as  a  rule,  trivial,  unless  gon- 
orrhoea, soft  chancre,  or  syphilitic  infections  occur.  Occasionally  vul- 
var abscesses  or  thrombosis  have  occurred.  Among  the  rare  conse- 
quences, gangrene  is  mentioned,  but  the  few  recorded  cases  of  this  seem 
to  have  been  really  noma  of  the  vulva,  occurring  independently  and 
wrongly  attributed  to  violence. 

An  examination  of  the  assailant  should  be  made  as  early  as  possible 
for  signs  of  scratching  or  bruises,  indicating  attempts  at  defence  by  the 
victim,  as  well  as  for  signs  of  recent  coitus,  seminal  stains,  or  blood  upon 
the  shirt  or  drawers.  The  general  state  of  muscular  power  should  be 
noted  and  compared  with  that  of  the  victim;  the  hands  and  nails 
examined  with  special  thoroughness,  if  scratches  exist  upon  the  victim. 
An  inquiry  into  the  mental  condition  of  the  accused  as  to  sanity, 
responsibility,  and  unnatural  sexual  instincts,  should  be  made  in 
every  case. 

The  following  schedule  by  Lacassagne  will  serve  as  a  guide,  when  in- 
vestigating a  case,  to  guard  against  the  possible  danger  of  overlook- 
ing important  points. 

Lacassagne's  schedule  for  medico-legal  examination  of  a  case  of  rape 
or  iri(|c(;('nt  assault.    Aaine,  ag(!,  address.    Date,  day,  and  hour  of  visit. 

Freliminary  inquiry;  statements  about  occurrence  (let  children 
talk).  Examination  to  bo  made  early;  perineal  coitus  and  digital  at- 
terrif>ts  kept  in  mind.  Jiemember  frequency  of  simulation  and  false 
accusations. 


IQQ  A  TEXT-BOOK  OF  GYNECOLOGY 

A.  Examination  of  Victim. — General  condition — scrofulous,  lym- 
phatic. Local  condition  (examine  on  table  or  couch  in  a  good  light). 
Condition  of  thighs  and  abdomen — scratches,  bruises,  and  nail  marks. 
Labia  majora  and  minora,  clitoris  for  redness,  excoriation,  ecchymosis, 
ulcers.  Vestibule  and  vagina  (open  and  close  thighs  to  squeeze  out 
liquids).  Hymen — position,  form,  margin,  orifice,  folds;  defloration  by 
penis,  finger,  or  foreign  body  (assistant  to  draw  forward  labium  on  one 
side  while  expert  does  the  same).  Discharge — physical  character, 
amount;  microscopic,  examine  for  semen  and  gonococci.  Signs  of  mas- 
turbation— elongated  lesser  labia,  large  turgescent  clitoris,  dilated 
vagina,  pigmentation,  precocious  puberty  about  vulva,  hair,  and 
breasts.     Examination  of  anus  and  perineum. 

Suspicious  stains  on  body  or  clothing,  especially  chemise  or  drawers. 
Place  under  seal,  noting  date.  Examine  by  Florence  reaction  and  for 
spermatozoa;  also  for  evidence  of  other  origin  of  stain.  Absence  of 
spermatozoa  not  final. 

B.  Examination  of  Accused. — Physical  condition,  strength,  cuta- 
neous diseases.  Clothing  torn.  Injuries,  showing  resistance.  Sexual 
organs — size  and  appearance.  Peculiarities,  tattooing,  hernia  truss. 
Stains  of  blood  or  semen  about  person  or  clothing.  Urethral  discharge 
{look  for  semen  if  seen  very  promptly).  Chronic  purulent  discharge. 
Alleged  impotence.  Mental  condition  as  to  sanity  or  full  responsi- 
bility. 

Conclusions. — A.  (1)  Has  the  person  been  the  victim  of  rape  or  sex- 
ual assault?  (8)  How  has  the  assault  been  made?  (3)  Has  there  been 
perineal  coitus  or  intromission  of  the  penis  or  finger?  (4)  Is  there  red- 
ness, contusion,  or  laceration  of  the  parts  or  defloration?  (5)  Has  any 
■disease  been  communicated?  Is  such  disease  syphilitic?  (6)  It  will  be 
necessary  to  re-examine  in days  to  note  progress  of  wound. 

B.  (1)  Does  accused  show  traces  of  recent  or  old  venereal  disease? 
'(3)  Is  such  disease  of  same  nature  as  that  found  on  victim?  (3)  Are 
there  traces  of  a  struggle  or  of  suspicious  stains?  (4)  Is  accused  sub- 
ject to  bodily  infirmity  making  coitus  impossible?  (5)  Is  his  mental 
■condition  normal  or  otherwise? 

Indecent  Assault. — In  a  large  proportion  of  cases  the  victim  is  usu- 
ally a  little  girl  under  ten  years.  The  attempt  is  most  often  made  with 
the  finger.  As  a  rule,  the  signs  of  a  struggle  are  absent,  and  on  this 
account  the  establishment  of  direct  proof  is  often  impossible.  The 
local  evidences  are  usually  slight  inflammation  and  reddening  with  or 
without  laceration  of  the  hymen.  A  slight  discharge  often  follows. 
The  method  of  examination  is  the  same  as  in  cases  of  rape. 

In  such  cases  care  must  be  taken  to  exclude  local  conditions,  which 
frequently  cause  spontaneous  vulvo-vaginitis  in  children.  The  pres- 
ence of  the  gonococcus  is  significant,  but  the  possibility  of  infection 
from  other  children  or  from  members  of  the  family  must  be  borne  in 
mind. 

Evidences  of  masturbation,  such  as  an  elongated  or  turgescent  cli- 


INJURIES  OF   THE  EXTERNAL   GENITAL   ORGANS  Id 

toris  with  pigmented  labia,  should  be  looked  for.  The  pigmentation  is 
usually  unilateral.  It  must  be  borne  in  mind  that  children  are  naturally 
mendacious,  and  may  either  originate  a  story  of  assault  themselves, 
or  accept  one  suggested  to  them  by  their  j^arents,  or  by  leading  ques- 
tions put  to  them  by  their  parents,  or  by  leading  questions  put  to  them 
in  the  course  of  the  medical  examination. 

Fournier's  classical  advice  to  medical  men  charged  with  the  inves- 
tigation of  these  cases,  that  one  should  close  his  ears  and  open  his  eyes, 
is  to  be  kept  constantly  in  mind.  Another  excellent  rule  is  to  refuse 
to  give  a  medical  certificate  to  be  used  by  the  friends  of  the  plaintiff  as 
the  basis  of  the  case. 

The  civil  consequences  of  injuries  to  the  female  genital  organs  have 
been  but  little  studied  or  described.  C.  Thiem  was  the  first  to  sys- 
tematize and  collate  our  knowledge  on  the  subject,  and  since  then  a 
fair  number  of  observations  have  been  recorded. 

The  disabilities  resulting  from  injuries  may  be  classified  as  follows: 

G-ynecological  effects  of  injury  in  relation  to  disability  and  claims 
for  damage. 

The  effects  of  accident  and  injury  upon  the  female  genital  organs 
may  be  classified  as  follows : 

1.  Malposition  of  uterus  due  to  accident. 

2.  Injury  to  perineum  and  vagina. 

3.  Injury  to  vulva. 

4.  Injury  to  uterus. 

5.  Injury  to  uterine  appendages. 

Occasionally  the  injury  may  be  the  sole  cause.  More  often  it  may 
act  by  aggravating  existing  disease.  It  is  important  to  remember  that 
the  condition  must  be  shown  to  arise  from  a  single  act  of  traumatism 
or  overexertion,  to  be  considered  as  the  effect  of  accident. 

There  is  no  evidence  to  show  that  retroversion  of  the  nonpregnant 
uterus,  or  that  anteversion,  or  anteflexion,  or  retroflexion,  is  ever 
primarily  a  result  of  accident  in  healthy  ^^ersons. 

Any  of  the  above  malpositions,  if  already  existing,  may  be,  however, 
aggravated  by  falls,  or  contusions  of  the  pelvic  region. 

Prolapse. — A  number  of  cases  are  reported  by  Thiem  and  others 
where  prolapse  has  followed  accidental  straining  and  heavy  lifting. 
The  proof  needed  to  establish  this,  is  sudden  and  painful  onset  with 
swelling,  oedema,  and  tendency  to  inflammation  of  the  prolapsed  parts. 
This  should  immediately  follow  the  alleged  accident  or  should  produce 
a  certain  amount  of  immediate  disability.  A  thickened  or  smooth  con- 
dition of  the  prolapsed  portion,  with  signs  of  ulcers  from  attrition,  and 
ease  of  reposition,  should  readily  enable  old  cases  to  be  excluded.  It 
may  be  assumed  that  prolapse  only  occurs  as  a  result  of  accident  in  per- 
sons locally  predisposed  to  it.  The  amount  of  disability  (loss  of  earning 
power)  in  the  labouring  classes  is  from  ten  to  tweifty-five  per  cent, 
according  to  the  success  with  whicli  rc))osition  by  supports  can  be  main- 
tained. Operation  can  not  1je  insisted  upon  if  o]jj(;cted  to.  The 
12 


162  A  TEXT-BOOK  OF  GYNECOLOGY 

aggravation  of  an  existing  prolapse  by  accident  may  also  require  com- 
pensation. 

Injuries  to  the  perineum  and  vagina  occur  usually  through  falls  in 
a  straddling  position  or  from  impalement;  they  generally  leave  no  per- 
manent disability  if  the  immediate  effects  are  recovered  from.  Lacera- 
tion of  the  posterior  vaginal  wall  is  the  most  serious  lesion.  Indirect 
laceration  from  forcible  separation  of  the  thighs  during  falls  has  been 
observed.  The  effects  are,  of  course,  most  serious  when  this  occurs  in 
pregnant  women. 

In  injuries  of  the  vulva  and  vaginal  orifice,  hematoma  is  the  com- 
monest result  of  injury.  It  leaves  no  permanent  disability.  Tumours 
of  the  vulva  have  not  yet  been  recorded  as  the  result  of  a  single  injury. 

Uterus. — The  nonpregnant  uterus  is  only  liable  to  injury  in  con- 
nection with  some  very  severe  violence,  such  as  fracture  of  the  pelvis; 
but  when  enlarged  from  tumours  or  pregnancy  it  becomes  exposed  to 
external  trauma;  interruption  of  pregnancy,  if  such  exists,  is  liable  to 
occur,  but  often  does  not. 

Cases  of  pelvic  hematocele  from  trauma  have  been  reported,  but  in 
those  cases  where  metrorrhagia  ensues,  the  existence  of  pregnancy  is. 
extremely  probable.  The  abdominal  hemorrhage  from  ruptured  tubal 
pregnancies  is  practically  never  due  to  trauma.  Torsion  of  the  pedicle 
of  ovarian  tumours  was  found  by  Thornton  to  be  traumatic  in  16  per 
cent  of  six  hundred  cases.  Laceration  and  hemorrhage  of  ovarian 
tumours  from  contusions  of  the  abdomen  have  been  observed. 

Hydrosalpinx  and  pyosalpinx  never  arise  from  trauma. 


CHAPTEE    XVI 

INFECTIONS  OF   THE   EXTERNAL   GENITAL  ORGANS 

Preliminary  remarks — Vulvitis  and  vaginitis — Bacteriology  of  the  external  genital 
organs — Mixed  infections — Gonorrhoea — Extirpation  of  the  vulvo-vaginal 
glands — Tuberculosis;  vulva;  vagina — Erysipelas — Erysipelas  and  puerperal 
infection — Diphtheria — Aphthae — Aerogenous  infection — Bilharzia — Chancroid 
— Hard  chancre — Late  syphilitic  ulcers. 

Infection  of  the  vulva,  the  vulvo-vaginal  gland,  and  the  vagina,  de- 
pending upon  the  action  of  specific  micro-organisms,  may  or  may  not 
be  limited  to — i.  e.,  arrested  within — the  intrauterine  segment  of  the 
genital  tract.  There  is  a  proneness  on  the  part  of  particularly  the  more 
vigorous  pathogenic  bacteria  to  progressively  invade  contiguous  mucous 
areas;  it  follows,  therefore,  that  infection,  once  established  in  the  vulva 
or  vagina,  is  liable  to  extend  upward,  involving  the  endometrium,  the 
mucous  lining  of  the  Fallopian  tubes,  the  peritoneum,  and  the  intra- 
pelvic  l3anphatics.  A  proper  comprehension  of  the  general  subject  of 
infection  of  the  female  genitalia  involves,  therefore,  a  study  of  the 
various  pathogenic  bacteria  (see  Sepsis),  a  consideration  of  the  micro- 
organisms known  to  be  involved  in  the  infection  of  these  organs,  and, 
finally,  a  study  of  the  infection,  not  alone  of  any  one  organ,  but  of 
the  entire  genital  apparatus. 

Vulvitis,  or  inflammation  of  the  vulva,  and  vaginitis,  or  inflamma- 
tion of  the  vagina,  were  formerly  recognised  as  clinical  entities;  at 
present,  however,  vulvitis  is  discussed  under  the  various  forms  of  skin 
disease  of  the  vulva,  or  as  the  result  of  the  action  of  micro-organisms 
or  of  traumatism,  while  vaginitis  can  hardly  longer  be  said  to  exist 
except  as  the  result  of  either  infection  or  injury.  Inflammations  of  the 
external  genital  organs  or  of  any  part  of  them,  except  such  as  occur  in 
the  recognised  forms  of  skin  disease  (see  Disease  of  the  Skin  of  the 
Female  Genitals),  will,  therefore,  be  discussed  under  the  heads  of  In- 
fections and  Injuries. 

Bacteriolog-y  of  the  External  Genital  Organs. — The  bacteriology  of 
the  vulva  and  vagina  in  both  health  and  disease  has  been  very  carefully 
investigated  by  numerous  observers.  Pioneer  work  was  done  by  Hauss- 
nian,  Kehrer,  and  Karewski,  with  primitive  methods  of  investigation 
which  naturally  militated  against  the  accuracy  of  their  results. 
Stroganofl',  of  St.  Petersburg,  has  investigated  the  bacteriology  of  tlie 
vagina  of  the  newboiTi  child,  and  finds  tliat  it  is  free  from  niicro-organ- 

163 


164  A   TEXT-BOOK  OP   GYNECOLOGY 

isms,  which,  however,  may  enter  soon  after  birth.  Baths,  washings,  and 
esjDecially  the  application  of  oleaginous  substances,  such  as  are  fre- 
quently used  in  the  early  toilet  of  newborn  children,  favour  the  entrance 
of  germs.  Yfinter  {C entraTblatt  fiir  Gyndkologie,  No.  17,  1888)  found 
numerous  organisms  in  the  vagina  and  upon  the  j^ndendal  structures, 
in  neither  of  which  were  there  any  manifestations  of  disease.  An  in- 
teresting fact  was  that  he  found  staphylococci,  including  the  Pyogenes 
albus,  aureus,  and  citretis,  together  Avith  numerous  streptococci,  all  of 
which,  in  morphology,  pigmentation,  and  behaviour  in  culture  media, 
were  identical  with  similar  bacteria  found  in  other  loci  where  they 
possess  pathogenic  properties;  they  differed,  however,  in  the  particular 
that  inoculation  experiments  indicated  that  they  were  innocuous.  All 
investigators  agree  that  all  pathogenic  bacteria  lose  their  virulence  the 
nearer  the}^  approach  the  cervix.  This  circumstance  at  once  raises  the 
question  whether  or  not  the  cervical  and  vaginal  secretions .  have  the 
effect  of  depriving  these  bacteria  of  their  virulence. 

In  answer  to  this  question  may  be  cited  the  observations  of  Doder- 
iein,  who  has  found  a  bacillus  which  does  not  grow  upon  many  of  the 
usual  media,  but  may  be  cultivated  on  sugar  bouillon  and  sugar  agar. 
It  produces  an  acid,  apparently  lactic,  upon  which  the  usual  acidity  of 
the  vaginal  secretion  depends.  Lactic  acid,  which  is  elaborated  by  this 
bacillus  in  considerable  quantity,  is  presumed  to  be  the  agent  which 
either  destroys  the  life  or  neutralizes  the  virulence  of  the  pathogenic 
organisms.  In  confirmation  of  this  theory  large  quantities  of  pus- 
producing  organisms  introduced  within  the  vagina  disappeared  com- 
pletely within  a  few  days.  This  acid-forming  bacillus,  which  stands 
as  a  sentinel  at  the  introitus  and  along  the  vaginal  wall,  does  not  itself 
produce  pathologic  s3^m])toms,  and  consequently  plays  no  part  in  the 
causation  of  sepsis.  Doderlein  is  of  the  opinion  that  this  micro-organ- 
ism and  the  products  of  its  vitality  are  able  to  resist  the  invasion  of 
streptococci,  which  probably  never  reach  the  uterus  unless  either  car- 
ried there  mechanically  or  escorted  by  the  more  powerful  pus-form- 
ers. These  latter,  notably  the  gonococcus,  overpower  the  bacillus  of 
Doderlein  and  march  practically  unopposed  to  the  remotest  reaches 
of  the  genital  tract.  The  fact  that  the  Bacillus  aerogenes  capsulatus 
manifests  its  activities  upon  or  near  the  cervix  indicates  that  it  is  not 
amenable  to  the  influence  of  this  micro-organism. 

The  importance  of  bacteriological  examination  of  secretions  found 
upon  the  vulva  and  in  the  vagina  can  hardly  be  overestimated.  The 
lesson  taught  by  the  investigations  of  Doderlein  and  J.  Whitridge 
Williams  is  conclusive  upon  this  point.  The  investigations  of  these  gen- 
tlemen show  that  the  normal  vaginal  secretion  is  of  very  small  quantity, 
of  whitish,  crumbling  material,  of  the  consistence  and  appearance  of 
curdled  milk,  containing  no  mucus,  and  giving  an  intensely  acid  reac- 
tion to  litmus,  while  microscopically  it  consists  entirely  of  vaginal 
epithelial  cells  and  a  relatively  few  large  bacilli.  The  pathologic  secre- 
tion, on  the  other  hand,  is  of  a  yellowish  or  greenish-yellow  colour. 


INFECTIONS  OB^  THE   EXTERNAL   GENITAL   ORGANS         165 

creamlike  in  consistence,  often  containing  gas  bubbles  (dependent  upon 
Bacillus  aerogenes  capsulatus)  and  a  little  mucus,  and  varies  in  reac- 
tion from  v/eakly  acid  or  neutral  to  alkaline,  while  microscopically  it 
consists  of  epithelial  cells,  numerous  pus  corpuscles,  and  all  kinds  of 
bacilli.  Stroganoff  found  that  micro-organisms  seemed  to  increase  in 
abundance  in  the  vaginal  secretion  preceding  and  following  menstru- 
ation. 

J.  Whitridge  Williams  made  a  critical  study  of  the  secretion  in  the 
vaginse  of  ninety-two  pregnant  women,  upon  which  he  based  prac- 
tical conclusions  (Transactions  of  the  American  Gynecological  Society, 
1898)  as  follows: 

1.  We  agree  with  Kronig  that  the  vaginal  secretion  of  pregnant 
women  does  not  contain  the  usual  pyogenic  cocci,  having  found  the 
Staphylococcus  epidermidis  albus  only  twice  in  ninety-two  cases,  but 
never  the  Streptococcus  pyogenes  or  the  Staphylococcus  aureus  or  albus. 

2.  The  discrepancy  in  the  results  of  the  various  investigators  is  due 
to  the  technique  by  which  the  secretion  is  obtained. 

3.  As  the  vagina  does  not  contain  pyogenic  cocci,  auto-infection 
with  them  is  impossible;  and  when  they  are  found  in  the  puerperal 
uterus,  they  have  been  introduced  from  without. 

4.  The  gonococcus  is  occasionally  found  in  the  vaginal  secretion, 
and  during  the  puerperiurn  may  extend  from  the  cervix  into  the  uterus 
and  tubes. 

5.  It  is  possible,  but  not  yet  demonstrated,  that  in  very  rare  in- 
stances the  vagina  may  contain  bacteria,  which  may  give  rise  to 
saprtemia  and  putrefactive  endometritis  by  auto-infection. 

6.  Death  from  puerperal  infection  is  always  due  to  infection  from 
without,  and  is  usually  due  to  neglect  of  aseptic  precautions  on  the  part 
of  the  physician  and  nurse. 

7.  Puerperal  infection  is  to  be  avoided  by  limiting  vaginal  examina- 
tions as  much  as  possible  and  cultivating  external  palpation.  When 
vaginal  examinations  are  to  be  made,  the  external  genitalia  should  be 
carefully  cleansed  and  disinfected,  and  the  hands  rendered  as  aseptic  as 
if  for  a  laparotomy.  Vaginal  douches  are  not  necessary,  and  are  prob- 
ably harmful. 

Mixed  Infections. — A  brief  consideration  of  the  preceding  para- 
graphs relative  to  the  bacteriology  of  the  external  genital  organs  makes 
it  evident  that  they  are  the  frequent  seats  of  coincident  infections  by 
different  micro-organisms.  In  cases  of  pelvic  suppuration  discharging 
into  the  genital  tract,  both  staphylococci  and  streptococci  are  generally 
found,  together  with  other  pathogenic  micro-organisms.  In  gonorrhoea 
the  diplococcus  of  Neisser  is  never  the  only  pyogenic  organism  pres- 
ent; and  in  the  destructive  stages  of  tuberculosis  the  tubercle  bacillus 
is  always  found  in  association  with  other  germs.  There  are  cases,  how- 
f'vcr,  in  which  the  pathologic  changes  and  clinical  yihenomena  are  so 
distinctly  attrilnitable  to  a  particular  micro-organism  that  the  infection 
is  given  its  name.'  rather  than  tliat  of  its  congeners.     Jn  this  category 


166  A  TEXT-BOOK  OF   GYNECOLOGY 

may  be  mentioned  particularly  (a)  gonorrhoea,  (b)  tuberculosis,  (c) 
erysipelas,  (d)  diphtheria,  (e)  aphthae,  and  (/)  aerogenous  infection. 

Gonorrhoea  in  women  was  once  thought  to  be  a  disease  restricted 
to  the  Tulva,  the  vagina,  and  tlie  urethra;  but  since  the  days  of  Tait 
and  JsToeggerath  it  is  known  that  infection  of  the  lower  genital  canal 
if  left  to  itself  may  become  a  progressive  invasion  of  the  mucous  tract, 
causing  infection  of  the  endometrium,  the  Fallopian  tubes,  the  peri- 
toneum, and  the  pelvic  lymphatics.  (See  Endometritis  and  Pyosalpinx.) 
It  should  be  remembered  likewise  that  the  lower  segment  of  the  urethra 
is  also,  coincidently  with  the  vagina  and  vulva,  a  seat  of  primary  infec- 
tion, and  that  from  this  locus  it  may  extend  upward,  involving  the 
bladder  and  even  the  kidneys.  (See  Cystitis.)  The  cause  of  this  infec- 
tion is  the  gonococcus  of  Neisser  (see  Fig.  17).  This  organism  is  the 
morbific  agent  that  is  distributed  chiefly  through  the  avenue  of  the 
"  social  evil,"  and  restrictive  measures  have  been  taken  in  all  enlight- 
ened communities  to  diminish  its  ravages.  The  prevalence  of  this 
micro-organism  in  the  vaginal  discharges  of  prostitutes  has  been  a  fre- 
quent subject  of  investigation.  Laser,  of  Konigsberg,  examined  a 
number  of  prostitutes  with  the  result  that  the  gonococcus  was  found 
in  the  urethra  111  times  in  353  cases;  in  the  vagina  7  times  in  180  cases; 
and  in  the  cervical  canal  21  times  in  67  cases.  These  figures  indicate 
that  this  micro-organism  finds  a  favourable  habitat  equally  in  the  ure- 
thra and  in  the  neck  of  the  uterus,  and  the  least  favourable  abiding 
place  in  the  vagina — a  conclusion  which  supports  the  observation  of 
Doderlein  relative  to  the  phagocytic  action  of  the  acid-forming  ba- 
cillus of  the  vagina.  Out  of  the  353  patients  examined  by  Laser  for 
gonococci  in  the  urethra,  four  fifths  of  the  111  cases  that  revealed  this 
micro-organism  gave  no  macroscopical  evidence  of  gonorrhoea.  In  341 
patients  in  whom  no  gonococci  were  discovered,  there  was  more  or  less 
inflammation  of  the  mucosa,  often  with  a  suspicious  discharge.  It 
follows,  therefore,  that  while  infection  of  the  genital  and  urinary  tracts 
may  depend  upon  organisms  other  than  the  gonococcus,  the  latter,  in 
a  degenerated  form  located  deep  in  the  mucous  folds  and  follicles,  but 
especially  in  the  crypts  of  the  vulvo-vaginal  gland,  may  be  a  persistent 
cause  of  the  disease,  even  when  it  can  not  be  detected  in  the  dis- 
charges. It  is  evident  from  these  facts  that  gonorrhoea  in  women 
should  be  classified  as  acute  and  chronic. 

Afanassiew  (Gazette  de  gynecologie,  No.  167,  p.  173)  reports  the 
results  of  bacteriological  investigation  of  the  lochia  of  twenty-four  par- 
turient women.  Out  of  sixty-eight  examinations,  he  obtained  cultures 
in  nearly  all  the  cases.  The  bacteria  diminished  in  the  vagina  from 
without  inward,  and  were  fewest  at  the  uterine  cavity — an  observation 
confirmatory  of  the  conclusions  of  Doderlein.  They  were  living  and 
culturable,  notwithstanding  daily  washing  of  the  canal  with  carbolized 
water  of  2-per-cent  strength. 

The  gonococcus  of  ISTeisser  is  often  demonstrable  in  secretions  from 
the  vagina  and  vulva.    These  organisms  are  frequently  found  in  appar- 


INPEGTIONS  OP   THE   EXTERNAL   GENITAL   ORGANS         167 

'eiitly  nonpurulent  secretions  long  after  the  period  of  acute  infection 
has  passed;  their  virulence,  however,  under  such  circumstances  is  gen- 
'Crally  greatly  reduced,  often  to  the  degree  of  having  lost  their  patho- 
genic properties.  (See  Gonorrhrea  in  Women.)  Freymuth  and  Pe- 
truschky  {Deutsche  medicinische  Wochenschrift)  have  found  the  diph- 
theria bacillus  in  noma  of  the  vulva.  The  same  organism  has  been  dem- 
onstrated in  exfoliative  vaginitis  not  associated  with  gangrenous  ulcera- 
tion, while  Eisner  and  others  have  reported  puerperal  diphtheria  in- 
volving the  vagina  and  endometrium.  The  Oidium  albicans  has  been 
■demonstrated  in  ajjlithous  inflammations  of  the  vulva  and  vagina  in 
both  children  and  adults. 

The  symptoms  of  acute  goiiorrhwa  in  women  consist  of  a  burning 
pain  on  urination  located  at  first  in  the  meatus  urinarius,  and  next  upon 
the  inner  and  erythematous  surfaces  of  the  vulvar  folds;  and  in  a  copious 
creamy  discharge,  bathing  the  vulva  and  matting  the  pudendal  hair. 
On  inspection  the  vulva  reveals  areas  of  erythema,  which,  after  a  few 
'days,  owing  to  the  destruction  of  the  epithelium,  may  become  distinct 
erosions;  the  urethra  is  tender  to  the  touch,  swollen,  and  its  mucous 
membrane  is  more  or  less  everted  at  the  meatus  urinarius.  The  diagno- 
sis may  be  made  presumptively  upon  the  foregoing  symptoms  coupled 
with  the  fact  of  probable  exposure  to  infection;  but  it  can  be  made 
positively  only  upon  the  demonstrated  presence  in  the  discharge  of 
the  gonococcus  of  ISTeisser.  The  practitioner  should  be  very  cautious 
in  giving  a  final  diagnosis  of  suspected  cases  of  gonorrhoea,  on  account 
•of  the  possible  social  and  medico-legal  contingencies  that  may  arise. 
The  symptoms  of  chronic  gonorrhcea  in  women  are  more  obscure.  There 
is  generally  a  history  of  a  preceding  acute  attack,  the  exact  character 
of  which  may  not  be  known  to  the  patient  herself,  but  which  can 
be  determined,  at  least  approximately,  by  well-directed  interrogatories. 
Following  the  supposed  cure  of  the  acute  attack  there  has  been  a  per- 
sistent catarrhal  discharge,  varying  in  colour  from  a  whitish  to  a 
slightly  yellowish  tint,  and  varying  in  quantity  from  slight  to  consider- 
able. If  these  conditions  exist  associated  with  a  present  or  a  past  sup- 
puration of  the  vulvo-vaginal  glands,  and  if  there  is  a  petechial  pur- 
plish red  area  about  the  orifice  of  the  vulvo-vaginal  ducts,  the  presump- 
tion of  chronic  gonorrhoea  is  strengthened.  If  the  mischief  in  the 
vulvo-vaginal  glands  has  gone  to  the  extent  of  suppuration,  resulting 
in  fistula;  or  cystic  degeneration,  the  diagnosis  may  be  considered  as 
•confirmed.  The  involvement  of  the  urethra,  dark -red  spots  upon  a  yel- 
lowish-white streaked  base  upon  the  vulva,  and  venereal  warts,'  are  com- 
plications of  conclusive  diagnostic  significance.  Oskar  Bodenstein 
(I)enlsche  medicinische  Wochenschrift)  quotes  Sanger  to  the  efl^ect  that 
the  local  application  of  a  50-per-cent  solution  of  zinc  chloride  will 
cause  the  granules  in  the  vaginal  mucous  membrane  to  spring  into 
vc]]('S  in  chronic  gonorrhrxia — a  convenient  diagnostic  expedient  that  is 
•certainly  worthy  of  inv(!stigation. 

7'///;  pathology  of  goaorrhwa  in  women  has  been  understood  but  re- 


168  A   TEXT-BOOK   OF   GYNECOLOGY 

cently.  Its  comprehension  involves  a  study,  not  so  much  of  the  changes 
that  occur  in  the  vulva,  vagina,  and  urethra,  as  of  those  occurring  in 
the  bladder  and  kidneys,  and  in  the  uterus  and  its  adnexa,  to  the 
chapters  upon  which  subjects  the  reader  is  referred.  The  pathology 
of  gonorrhoeal  infection  of  the  vulva  and  vagina  is  essentially  the 
pathology  of  an  infective  inflammation.  The  micro-organisms,  find- 
ing a  lodgment  upon  the  mucous  surfaces  of  the  urethra,  in  the 
muco-cutaneous  folds  of  the  vulva,  or  those  about  the  introitus 
vaginae,  readily  23ropagate  in  the  secretions  which  act  as  culture  media. 
The  direct  irritating  influence,  both  of  the  organisms  themselves  and 
of  the  products  of  their  vitality,  results  in  the  establishment  of  the 
ordinary  phenomena  of  inflammation — congestion,  stasis,  exudation, 
etc.  The  direct  action  of  these  organisms  and  their  products  is,  to  a 
certain  extent,  destructive  of  the  epithelium,  which,  however,  would 
probably  withstand  the  assaults  of  the  invaders  if  it  were  not  for  the 
circulatory  and  nutrient  changes  in  progress  in  the  underlying  struc- 
ture. Through  these  combined  influences  the  protective  epithelium  is 
broken  down  and  there  is  more  or  less  direct  invasion  of  the  under- 
lying cutictilar  structure;  but  even  here  the  intrusive  cocci  are  con- 
fronted by  other  defenders  of  the  system  in  the  form  of  leucocytes. 
Cocci  develop  rapidly,  however,  overcome  their  cellular  antagonists, 
and  find  their  Avay  into  the  fimbriated  intercellular  substance  and  intO' 
pre-existing  cells  of  the  tissue  and  in  the  vessel  walls.  While  these 
changes  are  in  progress,  however,  the  mucous  follicles  are  invaded,  and 
with  the  first  temporary  recession  of  the  local  circulatory  pressure  these 
follicles  are  stimulated  to  extreme  activity,  manifested  in  that  hyper- 
secretion which  is  generally  designated  as  catarrlial.  In  the  presence  of 
a  virulent  infection  these  follicles  and  glands,  including  even  the  vulvo- 
vaginal glands,  may  suffer  the  loss  of  their  epithelium  and  themselves 
become  the  avenues  for  tissue  infection.  Local  abscesses  as  the  result 
of  gonococcus  infection  but  rarely  occur,  except  in  the  vulvo-vaginal 
gland,  the  efferent  duct  of  which  may  become  occluded,  converting  the 
gland  into  a  suppurating  retention  cj^st.  Tissue  invasions,  such  as  have 
been  described,  more  frequently  result  in  permitting  the  passage  of  the 
pyogenic  organisms — for  by  this  time  the  infection  has  generally  become 
more  or  less  mixed — into  the  lymph  channels,  whence  they  are  carried 
to  the  lymphatic  glands,  particularly  to  those  in  the  groin,  where,  not 
infrequently,  the  infection  results  in  abscesses.  Coincidently  with  these 
changes  there  occurs  more  or  less  systemic  intoxication,  expressed,  it 
may  be,  by  an  initial  rigour;  this  is  followed  by  an  elevation  of  tem- 
perature, which  persists  with  slight  but  irregular  vacillation  until  the 
focus  of  suppuration  has  been  opened  and  drained. 

Treatment. — When  gonorrhcea  is  limited  to  the  vulva,  the  urethra, 
and  the  ostium  vaginae,  it  should  be  treated  by  rest,  and  antiseptic 
lotions  of  either  boric  acid  or  bichloride  of  mercury  emollient  appli- 
cations. The  vagina  will  seldom  be  invaded  unless  the  infection  is 
carried  upward  by  mechanical  means.     This,  however,  is  what  unfor- 


INFECTIONS  OF   THE  EXTERNAL   GENITAL   ORGANS  169 

tiinately  happens  in  the  majority  of  eases  long  before  the  physician  is 
consulted.  The  patient  of  her  own  accord  is  prone  to  use  the  douche; 
or,  may  be  before  she  has  become  aware  of  her  condition,  she  has 
indulged  in  repeated  acts  of  coition.  The  physician  is,  therefore,  called 
upon  at  the  very  outset  to  treat  a  thoroughly  infected  vagina.  Under 
these  circumstances  there  is  no  disease  with  which  women  are  afflicted 
that  calls  for  more  prompt,  more  vigorous,  and  more  efficient  treatment 
than  that  of  acute  gonorrhoea.  Its  probable  extension  to  the  upper 
reaches  of  the  genital  tract,  with  the  inevitable  complications  thereby 
engendered,  should  stand  before  the  practitioner  as  a  spectre  warning 
him  to  the  fullest  discharge  of  his  duty.  The  treatment  of  acute  gonor- 
rhoea is  essentially  bactericidal.  It  should  begin  with  a  thorough  cleans- 
ing of  the  parts;  this  can  be  accomplished  thoroughly  only  by  first 
shaving  the  pudendum;  a  douche  of  tepid  water,  either  clear  or  holding 
in  solution  some  borax  or  sodium  bicarbonate,  should  be  used  to  cleanse 
the  vulva  and  the  vagina;  after  this  has  been  thoroughly  done  another 
douche  of  l-to-3,000  bichloride  solution  should  be  employed  for  a  period 
of  from  ten  to  fifteen  minutes.  This  douche  should  be  given,  as  should 
the  preceding,  with  the  patient  lying  upon  her  back,  her  buttocks  drawn 
to  the  edge  of  the  bed,  in  which  position  the  nurse  can  practise  most 
thorough  cleansing  of  the  vagina  by  repeatedly  holding  her  hand  over 
the  vulva, thus  forcing  the  retention  of  the  irrigating  fluid  in  the  vagina; 
the  hydrostatic  pressure  thus  exercised  will  occasion  that  degree  of  dis- 
tention of  the  vagina  which  will  cause  an  obliteration  of  the  folds  and 
the  exposure  of  its  entire  surface  to  the  action  of  the  medicament. 
Care  should  also  be  taken  to  bring  the  antiseptic  solution  in  contact 
with  every  part  of  the  infected  area  of  the  Yulva.  An  older  and  pos- 
sibly more  efficacious,  but  certainly  more  severe,  treatment  consists  in 
cleansing  the  parts  as  above  described,  and  in  then  introducing  a  specu- 
lum, widely  distending  the  mucous  membrane  of  the  vagina,  which, 
with  the  entire  vulvar  surface,  is  cauterized  with  a  solution  of  nitrate 
of  silver,  twenty  grains  to  the  ounce;  this  cauterization,  to  be  effective, 
should  be  thorough  and  should  include  every  part  of  the  mucous  mem- 
brane. After  the  silver  nitrate  has  been  applied,  a  loose  pledget  of  cot- 
ton, saturated  with  glycerine,  should  be  carefully  inserted,  not  so  as  to 
pack  the  vagina,  but  to  lie  lengthwise  in  the  canal,  preventing  the  ap- 
proximation of  the  cauterized  surfaces.  Other  remedies,  such  as  the 
zinc  sulphate,  plumbic  acetate,  tannin,  carbolic  acid,  lysol,  and  creolin, 
have  been  suggested  and  may  be  employed;  they,  however,  possess  vary- 
ing germicidal  properties,  none  of  them  being  so  valuable  as  either  the 
mercuric  bichloride  or  the  silver  nitrate.  When  the  nitrate  of  silver  is 
used,  it  should  not  be  reapplied  under  three  or  four  days.  It  should 
be  remembered  that  antiseptic  treatment,  to  be  effective,  should  be  con- 
tinued until  the  symptoms  of  infection  have  subsided.  It  is  not  enough 
to  kill  an  existing  goneration  of  bacteria,  even  though  it  were  possible 
to  do  so  in  a  given  case,  for  it  slioiild  be  remernbored  that  many  of  these 
micro-organisms  pr()|)agate  by  spores,  which  resist  more  effectively  than 


170  A  TEXT-BOOK  OP   GYNECOLOGY 

do  the  parent  organisms  themselves  the  action  of  germicidal  agents. 
Doderlein  has  emphasized  the  importance  of  repeated  disinfections  of 
the  genital  tract,  for  the  purpose  of  securing  sterilization,  and  his 
teachings  should  pass  into  an  axiom  of  practice.  The  treatment  of 
chronic  gonorrhoea  in  women  involves  a  much  more  comprehensive 
regimen.  It  must  he  based  upon  a  comprehension  of  the  pathologic 
changes  that  have  occurred  in  the  case  at  hand.  This  may  involve 
the  application  of  surgical  expedients  to  the  bladder,  the  kidneys,  the 
uterus  or  its  adnexa,  or  to  the  pelvic  lymphatics.  So  far  as  the  treat- 
ment of  chronic  gonorrhea  of  the  lower  genital  tract  is  concerned,  it 
will  resolve  itself  into  a  persistence  in  antiseptic  measures,  or  the  ex- 
tirpation of  the  vulvo-vaginal  gland,  which  is  generally  found  to  be  the 
persistent  fons  et  origo  of  the  disease.  The  antiseptic  treatment  should 
consist  in  the  continued  practice  of  irrigation  with  strong  solutions  of 
bichloride  of  mercury  or  carbolic  acid,  always  taken  in  the  recumbent 
posture,  the  douche  bag  being  elevated  from  four  to  five  feet  above  the 
patient,  the  nurse  practising  forced  retention  of  the  fluid  in  the  pa- 
tient's vagina.  It  should  be  kept  in  mind  that  chronic  gonorrhoea  of 
the  vagina  is  a  deep-seated  process,  for  the  successfid  treatment  of 
which  vaginal  distention  is  a  necessity.  Forcible  tamponade  of  the 
vagina,  particularly  in  the  lateral  fornices  and  in  the  upper  segment 
of  the  canal,  should  be  practised  by  saturating  a  long  slender  cotton 
tampon  with  sterilized  glycerine.  The  exosmotic  influence  of  this 
agent  has  a  tendency  to  wash  the  micro-organisms  out  of  their  hiding 
places  and  to  bring  them  in  contact  with  the  stronger  sterilizing  agents. 
In  these  cases  it  is  of  special  value  to  distend  the  vagina  to  the  extreme 
by  means  of  a  multivalvular  specidum,  and  to  cauterize  the  thus  tense 
and  distended  mucous  surface  with  a  strong  solution  of  nitrate  of  silver, 
followed  with  glycerine  tamponade.  The  escharotic  influence  of  the 
silver  salt  is  not  sufllcient  to  produce  serious  destruction  of  the  mucous 
membrane,  unless  frequently  applied — i.  e.,  oftener  than  every  three  or 
four  days. 

Extirpation  of  the  vulvo-vaginal  glands  should  be  practised  when- 
ever they  have  become  the  seat  of  gonorrhoeal  infection,  as  evidenced 
by  either  repeated  suppurations  or  cystic  degeneration.  This  gland  is 
also  the  occasional  seat  of  malignant  disease,  the  existence  of  which  is  an 
indication  for  its  prompt  removal.  This  is  an  operation  of  more  magni- 
tude than  the  anatomic  structures  involved  would  seem  to  imply.  With 
the  patient  in  the  dorsal  position,  the  vulva  having  been  completely 
sterilized,  the  labia  of  the  affected  side  are  retracted  by  the  hands  of  the 
assistant  or  nurse,  and  an  incision  is  made  over  the  gland  just  at  the 
base  of  the  labium  minus.  If  the  gland  is  distended,  dissection  should 
be  made  with  considerable  care  until  the  cyst,  as  the  gland  may  be  now 
designated,  is  encountered;  an  effort  should  be  made  to  carefully  enu- 
cleate this  body,  which  will  be  found  to  be  held  in  position  by  a  sort 
of  ligamentous  structure,  conveying  its  nerves  and  nutrient  vessels. 
These  are  of  sufficient  magnitude  to  occasion  severe  hemorrhage,  and 


INFECTIONS   OF   THE  EXTERNAL   GENITAL   ORGANS  lYl 

if  they  are  permitted  to  elude  the  grasp  of  the  operator,  they  retract 
along  the  vaginal  wall  to  such  an  extent  that  they  are  re-secured  with 
extreme  difficulty.  Care  should  be  taken,  therefore,  to  get  them  with- 
in the  grasp  of  a  hemostatic  forceps  before  excising  the  gland,  and 
to  ligate  the  pedicle  before  taking  off  the  forceps;  the  wound  should 
then  be  closed  aseptically  and  dressed  with  protective  pads.  If  closed 
by  the  buried  suture  the  liability  of  subsequent  infection  from  external 
causes  is  minimxized. 

Tuberculosis  of  the  vulva  is  a  specific  inflammatory  disease  of  the 
external  genitalia,  caused  by  the  presence  of  the  tubercle  bacillus  and 
characterized  by  both  the  anatomic  lesions  and  clinical  course  of  lupus. 
It  may  exist  as  a  primary  disease  confined  to  the  vulvar  region  or  a 
secondary  manifestation  of  tuberculous  lesions  in  the  lung,  intestine, 
or  internal  genital  organs. 

A  clear  definition  of  tuberculosis  of  the  vulva  is  extremely  difficult 
to  give  in  the  presence  of  the  confusing  classifications  of  different 
authors,  and  m.ust  in  reality  include  a  very  extended  description  and 
differentiation  of  the  conditions — ulcus  rodens  vulvae,  elephantiasis, 
lupus  vulva3,  Testhiomene,  and  destructive  ulcer.  Veit,  Schroder, 
Pozzi,  and  many  others  have  described  ulcus  rodens  vulvae  as  a  distinct 
lesion,  but  they  also  state  that  the  tubercle  bacillus  has  often  been  found 
in  such  ulcers.  It  will  certainly  simplify  the  subject  greatly  and  bring 
it  more  within  the  limits  of  this  short  article  to  look  upon  this  division 
as  suh  judice,  and  to  describe  only  a  tuberculosis  of  the  vulva. 

Etiology. — Until  recent  times  tuberculosis  of  the  vulva  has  been 
considered  so  rare  that  it  has  been  given  no  place,  or  only  passing 
mention,  in  the  accepted  text-books  of  gynecology;  but  the  reported 
cases  of  Demme,  Schenck,  Kuttner,  Karajan,  Paoli,  Kelly,  Eieck,  and 
others,  would  indicate  that  the  disease  occurs  with  greater  frequency 
than  is  generally  believed,  and  that  this  condition  must  always  enter 
into  the  diagnosis  of  vulvar  ulceration.  Barbier  {Gazette  medicale) 
believes  that  a  woman  can  be  infected  by  a  tuberculous  man  during 
coitus.  Bacilli  have  been  demonstrated  in  the  semen  as  well  as  in  the 
discharge  attending  tuberculous  epididymitis.  The  uterus  may  be  in- 
fected by  extension  from  a  tuberculous  growth  on  the  vulva,  without 
any  intermediate  trace  of  infection  in  the  vagina.  He  even  admits  the 
possibility  that  tuberculous  infection  may  be  transmitted  by  the  finger 
of  the  attendant,  by  unclean  instruments,  or  even  through  the  medium 
of  the  air.  It  is  manifest,  however,  that  infection  transmitted  in  this 
way  must  be  taken  up  through  some  rent  in  the  continuity  of  the  epi- 
thelium. 

The  disease  occurs  alike  in  children  and  adults  and  without  refer- 
ence to  the  general  nutrition.  The  infection  would  seem  to  be  by  the 
direct  inoculation  of  a  skin  abrasion  by  means  of  the  nails,  by  infected 
dust,  by  tuberculous  stools,  or  by  coitus.  The  case  of  Schenck  occurred 
in  a  chihl  who  bar]  two  tuberculous  y)laymates,  and  wlio  had  no  other 
tiihcrciilons  iiijiiiilV.'sijii  ions.     Prostitutes  arc  most  frequently  attacked, 


172 


A   TEXT-BOOK  OF  GYNECOLOGY 


a  fact  that  has  its  explanation  in  their  great  liabihty  to  direct  infection, 
in  continued  irritation,  and  in  lack  of  cleanliness.  Masturbation  serves 
as  a  predisposing  cause,  and  syphilis  also  by  lowering  the  resistance 
of  the  tissues.  Koch  has  considered  extirpation  of  the  inguinal  glands 
to  be  a  predisposing  cause. 

Morbid  Anatomy. — The  starting  point  of  the  tuberculous  process  is 
usually  in  the  region  of  the  urethral  orifice  or  the  clitoris,  or  in  the 
posterior  commissure.  The  lesion  begins  as  a  single  or  as  multiple 
hard  masses,  of  a  dark-red  or  livid  colour,  which  develop  in  an  indu- 
rated skin  and  increase  in  size  very  slowly.  This  mass  may  exist  for  a 
long  time  as  a  firm  nodule,  or  in  the  clitoris  as  a  hypertrophy,  or  it 
may  soften  in  the  centre  and  break  down  to  form  a  small,  raised,  un- 
healthy ulcer  with  ragged  edges,  which  exudes  a  serous  fluid.  It  is  in 
this  stage  of  ulceration  that  the  patient  usually  presents  herself  for 
treatment.  When  the  lesions  are  multiple,  a  number  of  such  discrete 
ulcers  will  form  on  the  vulva  and  gradually  run  together  to  form  an 
extensive  area  of  tuberculous  granulations  involving  the  entire  vesti- 
bule, clitoris,  labia,  and  lower  part  of  the  vagina.    The  granulations  of 

such  an  ulcer  are  un- 
healthy, friable,  do 
not  bleed  easily,  and 
show  no  tendency  to 
caseation.  The  sur- 
face is  covered  by 
a  sero-purulent  exu- 
date. There  is  a  rich 
vascularization  of  the 
part  and  the  tissues 
around  and  beneath 
the  ulcer  are  strongly 
infiltrated,  but  not 
markedly  indurated. 
These  ulcers  are  apt 
to  be  serpiginous  in 
character,  healing  be- 
hind as  the  advance  is 
made.  A  very  char- 
acteristic feature  of 
the  disease  is  a  rough, 
tense,  hard  elephanti- 
asic  thickening  of  the 
labia  or  clitoris,  or  both,  which  causes  them  to  swell  to  two  or  three  times 
their  normal  size.  In  fact,  in  the  cases  of  Karajan  and  De  Sinerty  the 
operation  was  done  for  elephantiasis  of  the  clitoris,  and  the  tuberculous 
nature  of  the  disease  was  revealed  only  by  histological  and  bacterio- 
logical examination.  A  microscopic  examination  of  these  ulcers  shows 
the  base  to  be  made  up  of  a  thin  layer  of  tuberculous  granulations  and 


Fig.  68. — "  A  low  power  shows  the  caseous  areas  (5,  c)  in  the 
tuberculous  tissue  and  an  occasional  fistulous  tract  («)." — 
Whitacre  (page  173). 


INFECTIONS   OP  THE  EXTERNAL   GENITAL   ORGANS  1^3 


Fig.  69. — "  A  high  power  picture  demonstrates  small  round 
cells  and  giant  cells  around  the  irregular  caseous  areas." — 
Whitacre. 


the  raised  edges  of 
solid  tuberculous  tis- 
sue containing  more 
or  less  typical  mili- 
ar}^ tubercles.  A  low 
power  (Fig.  68)  shows 
the  caseous  areas  in 
the  tuberculous  tis- 
sue and  an  occasional 
fistulous  tract.  A 
high  power  (Fig.  69) 
demonstrates  small 
round  cells  and  giant 
cells  around  the  ir- 
regular caseous  areas. 
Tubercle  bacilli  may 
be  demonstrated  (Fig. 
70)  among  the  small 
round  cells  in  the 
secretions  or  in  the 
newly  formed  tissue. 
It  must  be  remem- 
bered, however,  that  in  the  serpiginous  course  of  such  a  tuberculous 
lesion  the  older  parts  of  the  ulcer  may  show  the  entire  absence  of  tuber- 
cle bacilli,  as  is  shown  by  the  interesting  case  of  Rieck  (Fig.  71).  The 
involyement    of   the    urethra    is    progressive,    its    inner    surface    loses 

its  real  mucous-mem- 
brane character,  is 
more  or  less  exposed, 
and  may  be  con- 
verted into  scar  tis- 
sue. The  meatus  ap- 
pears to  be  torn  lat- 
erally, as  Emmet  has 
pictured  it  for  the 
cervix.  The  process 
continues  until  the 
urethra  is  almost  en- 
tirely destroyed  and 
is  represented  by  a 
funnel-shaped  ulcer. 
The  course  of  the 
ulcerative  process  is 
very  slow,  however, 
and      the      inguinal 

Fig.  70.— "Tub(;rcl(-  hiu'illi  may  be  demonstrated  among         glands      remain      free 

the  small  round  colls."— Whitaore.  '        for      a      remarkably 


174 


A  TEXT-BOOK   OF  GYNECOLOGY 


long  time.  Cicatrization  is  sometimes  associated  with  the  ulceration,  as 
an  evidence  of  a  tendency  to  spontaneous  healing,  and  may  lead  to  great 
deformity. 

Fistula?  often  form  a  marked  feature  of  the  disease,  and  especially 
in  ulcus  rodens  vulvse.  A  tendency  to  a  deep  penetration  of  the  tissues 
may  be  present  from  the  start.  They  first  form  underneath  the  mucous 
membrane,  but  very  soon  penetrate  deeply,  and  may  communicate  with 
the  rectum  high  up  at  the  upper  end  of  the  perineal  triangle.     Three 

or  four  sinus  open- 
ings on  the  vulva  may 
coalesce  below  the 
surface  and  open  into 
the  rectum  as  a  sin- 
gle channel.  Ulcera- 
tion in  the  perineal 
body  may  be  so  ex- 
tensive as  to  form  a 
cloaca. 

Symptoms.  —  The 
first  symptom  of  pri- 
mary tuberculosis  <)f 
the  vulva  is  often  a 
stinging  pain  on  uri- 
nation, caused  by  the 
urine  coming  in  con- 
tact with  a  minute 
ulcer  at  the  orifice 
of  the  urethra.  At 
other  times  an  ulcer  giving  no  symptoms  is  discovered  by  the  patient,  or 
the  nympha  of  one  side,  or  the  clitoris,  is  found  to  be  increasing  in  size. 
A  physical  examination  will  reveal  the  presence  of  one  or  more  ulcers 
possessing  the  above-named  characteristics.  The  course  of  such  an 
ulcerative  process  is  extremely  slow,  and  may  continue  for  many  years 
as  a  local  phenomenon  without  affecting  the  general  health  of  the 
patient.  The  dribbling  of  urine  and  rectal  irritation  will,  of  course,  be 
present  in  the  advanced  cases  as  most  distressing  symptoms.  Death  will 
eventually  result  from  involvement  of  the  internal  organs. 

A  secondary  tuberculosis  of  the  vulva  takes  a  much  more  rapid  and 
malignant  course;  furthermore,  the  vulvar  disease  often  possesses  little 
significance  in  comparison  with  the  primary  lesion  in  the  lung  or  other 
organs. 

Diagnosis. — The  diagnosis  of  this  condition  possesses  a  consider- 
able degree  of  importance,  first,  because  of  the  necessity  of  radical 
treatment,  and,  secondly,  because  of  the  difficulty  experienced  in  ar- 
riving at  a  correct  diagnosis.  Askanazy  has  explained  certain  of  these 
difficulties  by  the  demonstration  that  we  may  meet  with  tumours  not 
differing  in  their  microscopical  anatomy  from  typical  tuberculosis,  but 


Fig.  71. — The  oa><^'  uf  Kicck  :  A.  C,  sinus  openings ;  B,  F,  scar- 
tissue  ;  X*,  a  small  tumour  containing  typical  tubercle  tissue ; 
^, ulcerated  surface  ;  6^, urethra;  7/, introitus  vagina;  t7,ele- 
phantiasic  thickening  of  left  nympha. — Whitacee  (p.  173). 


INFECTIONS  OF   THE   EXTERNAL   GENITAL  ORGANS  I75 

characterized  clinically  by  an  absence  of  all  tendency  to  caseation, 
abnormally  large  size  of  tumour  formation,  firm  consistence,  and,  lastly^ 
by  a  tendency  to  fibrous  metamorphosis  which  may  eventually  lead  to 
a  complete  obliteration  of  all  specific  tuberculous  attributes. 

The  association  of  ulceration  with  elephantiasic  thickening  of  the 
labia,  the  slow  development,  the  chronicity  of  the  ulceration,  and,  most 
important,  the  demonstration  of  tubercle  bacilli  in  the  secretions,  will 
serve  to  distinguish  it  from  carcinoma.  Simple  elephantiasis  is  not 
associated  with  ulceration.  Chancroid  will  usually  be  diagnosed  by 
its  history  and  clinical  characteristics,  by  the  absence  of  elephanti- 
asis, by  its  multiple  character,  by  its  short  duration,  and  by  the  absence 
of  extensive  and  deep  destruction  of  tissue. 

Treatment. — The  treatment  of  tuberculous  lesions  of  the  vulva  is 
surgical,  and  a  radical  removal  of  all  diseased  tissue  should  be  resorted 
to  whenever  this  is  possible.  This  will  often  require  an  extensive  plas- 
tic operation,  and  it  should  be  remembered  that  a  considerable  removal 
of  urethral  tissue  can  be  made  without  impairing  the  function  of  the 
bladder  (Kelly,  Schroder,  Paoli).  When  this  is  not  possible,  thorough 
curetting  with  a  sharp  spoon,  followed  by  cauterization  with  strong 
acids,  may  be  tried  and  repeated  as  often  as  the  disease  recurs.  Deep 
cauterization  by  the  electro-puncture  serves  as  an  excellent  method  of 
thoroughly  removing  the  diseased  tissue  and  securing  good  cicatriza- 
tion. The  ulcers  unfortunately  heal  very  well  oftentimes  nnder  such 
simple  applications  as  iodine  or  acids,  but  this  cure  is  not  permanent, 
and  the  ulcers  recur.  Under  any  plan  of  treatment  these  cases  should 
be  carefully  followed  up  and  the  slightest  recurrence  treated  as  radi- 
cally as  the  original  focus  of  infection.  Enlarged  glands  in  the  groin 
should  be  removed  at  the  time  of  the  primary  operation  or  in  the  in- 
stance of  their  later  enlargement.  Either  as  an  auxiliary  to  the  ordi- 
nary methods  of  treating  lupus,  or  as  an  independent  method,  Unna  ad- 
vises (Monatshefte  filr  praMisclie  Dermatologie)  the  following  lotion: 
I^.  Corrosive  sublimate,  1  part;  carbolic  acid  or.  creosote,  4  parts;  alco- 
hol, 20  parts.  The  nodules  are  attacked  in  series  of  tens,  beginning 
with  those  at  the  edge  of  the  patch.  They  are  first  punctured  with  an 
acne  lance,  and  a  minute  shred  of  absorbent  cotton  moistened  with  the 
lotion  is  inserted  by  means  of  a  sharpened  stick,  the  cotton  rotated  and 
allowed  to  remain  for  ten  or  fifteen  minutes.  In  a  few  days  the  punc- 
tures and  lupus  deposits  so  treated  have  almost  disappeared,  and  other 
nodules  may  be  then  similarly  attacked.  This  method,  Unna  believes, 
has  many  advantages  over  the  somewhat  similar  plan  of  treatment 
by  means  of  the  nitrate-of-silver  stick. 

Tuberculosis  of  the  vagina  is  usually  associated  with  tuberculosis 
of  the  higher  portions  of  the  genital  tract,  but  a  number  of  cases  have 
been  reported  in  which  no  other  focus  could  be  discovered  in  the  genital 
tr-aet,  and  a  single  case  is  reported  by  Friedliinder  in  which  a  vaginal 
iiieer  reproseutefl  the  only  tuberculous  lesion  to  be  found  in  the  entire 
\)<)(\y.     'r\\(i  vagina  certainly  may  be  infected  from  a  tuberculosis  of 


176  A   TEXT-BOOK  OF  GYNECOLOGY 

the  peritoneum  or  tube  without  involvement  of  the  intervening  organs 
(Opj)enheim),  and  it  was  Reynaud  who  first  explained  the  usual  seat  of 
the  first  vaginal  lesion  in  the  posterior  fornix,  by  the  observation  that 
it  was  here  that  virus-laden  secretions  from  above  first  came  in  con- 
tact with  the  vagina.  The  infection  may  also  be  introduced  from  with- 
out by  coitus  with  men  suffering  from  a  tuberculous  disease  of  the  sexual 
organs,  by  the  hands  or  instruments  of  the  physician  or  midwife,  from 
the  urine,  from  filthy  bed  linen  or  wearing  apparel,  from  the  air,  from 
the  blood  (Davidsohn),  and  by  infection  in  continuity  of  tissue  from 
neighbouring  organs,  as  in  vesical  or  rectal  fistulas. 

The  infrequency  of  the  disease  in  both  the  vagina  and  vulva,  as 
compared  with  that  of  the  higher  organs,  is  probably  to  be  explained 
by  the  natural  resistance  of  squamous  epithelium  to  bacterial  invasion, 
and  it  is  only  after  injury,  abrasion,  or  the  action  of  irritating  secretions, 
that  the  tubercle  bacillus  can  gain  entrance  to  the  tissues. 

The  disease  occurs  Avith  greatest  frequency  during  the  period  of 
sexual  activity  (twenty  to  forty),  yet  seven  and  seventy-nine  represent 
the  two  extremes  of  age  in  the  collected  cases. 

Morbid  Anatomy. — Two  cases  in  particular  are  reported  where  the 
entire  lesion  consisted  in  an  eruption  of  perfectly  typical,  fresh  miliary 
tubercles  over  the  entire  vaginal  wall.  These  tubercles  were  of  millet- 
seed  size,  and  were  made  up  microscopically  of  giant,  epithelioid,  and 
small  round  cells,  which  were  supported  by  a  delicate  reticulum  and 
showed  areas  of  caseation.  Tubercle  bacilli  were  present.  Favoured  by 
moisture  and  warmth,  these  miliary  tubercles  soon  break  down  to  form 
minute  ulcers,  or  by  their  confluence  will  form  larger  sharply  defined 
but  irregular  ulcers.  Such  ulcers  are  characterized  by  perpendicular 
edges,  a  depressed  grayish  or  yellowish-gray  base,  studded  by  tubercles 
and  covered  by  caseous  material,  a  size  varying  with  the  extent  of  the 
confluence,  and  a  decided  tendency  to  the  serpiginous  type.  Such  an 
ulcer  is  usually  surrounded  by  an  area  of  hyperemia,  which  is  more  or 
less  filled  with  small,  yellow,  opaque,  grainlike  miliary  tubercles.  The 
usual  seat  of  ulceration,  as  has  already  been  stated,  is  in  the  posterior 
fornix.  When  the  infection  is  from  without,  however,  the  lower  por- 
tion of  the  vagina  will  be  first  involved.  Tuberculous  fistulse  are  found 
in  the  later  stages  of  the  disease  and  are  formed,  as  a  rule,  by  an  ulcera- 
tion into  the  connective  tissue,  thence  into  urethra,  rectum,  bladder,  or 
the  skin  surface  of  the  perineum.  On  the  other  hand,  fistulse  may  be 
the  result  of  perforating  rectal  or  vesical  ulcers,  and  cases  have  been 
reported  in  which  the  fistula  has  its  origin  in  a  broken-down  tubercu- 
lous Fallopian  tube.  These  fistulse  are  peculiar  only  in  the  fact  that 
they  are  lined  by  the  tuberculous  membrane. 

Symptoms. — The  sym]3toms  of  tuberculous  vaginitis  are,  as  a  rule, 
masked  by  those  of  the  tiiberculous  disease  existing  in  other  parts  of  the 
body.  A  leucorrhoea  associated  with  painful  coitus  or  pain  in  using  the 
douche  tube  will  usually  be  the  first  symptom  that  brings  the  patient 
to  the  physician  for  examination,  or  the  symptoms  of  a  vesico-recto- 


INFECTIONS  OP  THE  EXTERNAL   GENITAL   ORGANS  177 

vaginal  or  urethro-vaginal  fistula  may  be  the  first  that  are  referred  to 
the  vagina.  A  physical  examination  will  reveal  one  or  many  sensitive 
nlcers  possessing  the  above-named  characteristics. 

The  diagnosis  of  the  miliary  form  from  granular  vaginitis  should 
not  present  great  difficulties  when  we  remember  the  frequency  of 
the  latter  as  compared  to  the  condition  under  discussion,  also  its 
usual  association  with  pregnancy  and  gonorrhoea.  Furthermore,  the 
character  of  the  ulceration,  and  the  fact  that  a  tuberculous  lesion  of  the 
vagina  is  almost  invariably  associated  with  a  similar  lesion  elsewhere 
in  the  body,  will  prevent  confusion.  A  chancre  can  be  easily  distin- 
guished from  a  tuberculous  ulcer  by  its  history  and  clinical  course;  the 
papular  or  ulcerative  syphilides  by  the  history,  the  total  lack  of  pain, 
and  mainly  by  their  disappearance  under  antisyphiltic  treatment.  The 
reports  of  many  of  the  recorded  cases  state  that  the  patient  was  first 
subjected  to  antisyphilitic  treatment,  leading  to  the  impression  that 
this  confusion  often  arises.  Finally,  the  secretion  of  every  persistent 
ulceration  of  the  vagina  or  vulva  should  be  subjected  to  bacterial  ex- 
amination in  smear  or  culture  preparations,  or  inoculated  into  the  peri- 
toneal cavity  of  guinea-pigs.  The  number  of  bacilli  is  often  too  few 
for  easy  demonstration  by  ordinary  staining  methods,  yet  it  will  cause 
a  tuberculous  peritonitis  in  the  guinea-pig  in  from  three  to  four  weeks 
when  present  in  very  small  numbers.  A  microscopic  examination  of  a 
snipping  from  the  edge  of  the  ulcer  may  be  necessary  to  distinguish 
the  condition  from  carcinoma. 

The  treatment  of  tuberculous  vaginitis  should  be  as  radical  as  possible 
when  the  lesion  can  be  demonstrated  to  be  a  primary  one,  either  in  the 
genital  tract  or  in  the  body;  but  it  must  be  remembered  that  the  condi- 
tion is  usually  secondary  to  a  much  more  serious  tuberculous  involve- 
ment of  the  Fallopian  tubes,  the  uterus,  the  intestine,  or  the  lungs. 
In  these  cases  palliative  measures  alone  are  indicated.  When  complete 
excision  of  the  ulcers  is  possible  this  should  be  done,  but  we  must  very 
often  limit  ourselves  to  a  thorough  curetting  and  cauterizing  of  the 
ulcer,  and  a  prompt  treatment  of  every  point  of  recurrence.  Palliative 
measures  will  consist  in  local  applications  to  the  ulcers,  the  repair  or 
cleaning  of  fistulge,  the  maintenance  of  an  antiseptic  condition  by  the 
use  of  astringent  and  antiseptic  douches,  the  use  of  general  tonics — in 
fact,  the  use  of  those  measures  which  are  applicable  to  tuberculosis  in 
other  parts  of  the  body. 

Erysipelas  of  the  external  genital  organs,  and  particularly  infection 
of  the  genital  tract  by  the  Streptococcus  erysipelatos  (Streptococcus 
pyogenes),  are  occurrences  of  tragic  importance.  When  the  infection  is 
strictly  local,  the  streptococcus  finding  ingress  through  some  abrasion 
in  the  epithelium,  the  resulting  phenomena  are  those  of  erysipelas  in- 
volving the  pudendal  structures.  The  virus,  once  admitted  to  the  field 
of  |)ff)pagation,spreads  rapidly  through  the  lymph  capillariesof  the  sur- 
rounding skin.  The  symptoms  that  ensue  are  sudden  attack  of  febrile 
<listurbance  ushered  in  by  a  rigor;  the  tongue  becomes  coated,  there  is 
13 


178  A  TEXT-BOOK  OF   GYNECOLOGY 

a  sense  of  depression  over  the  stomach,  and  malaise,  with  possible  noc- 
turnal delirium;  swelling  of  the  infected  point  occurs,  associated  sooner 
or  later  with  generally  coincident  tenderness  in  the  inguinal  lym- 
phatics. The  swelling  in  the  vulva  progresses  rapidly  and  is  associated 
with  pain,  throbbing,  and  a  sense  of  heat  and  dryness;  itching  is  gener- 
ally an  early  and  persistent  spnptom,  while  diffuse  infiltration  occasion- 
ing oedema  of  the  cellular  tissue  of  the  vulva  rapidly  supervenes. 
Minute  vesicles  may  be  discovered,  usually  arranged  in  groups,  and 
manifesting  themselves  in  the  surface  of  the  skin.  The  smaller  of 
these  vesicles  commonly  rupture,  the  resulting  discharge  of  clear  or 
slightly  yellowish  serum,  occasionally  tinged  with  blood,  desiccates,  and 
forms  crusts.  The  characteristic  feature  of  this  inflammation  is  to 
spread  rapidly  from  the  point  of  primary  infection.  This  extension 
may  occur  until  it  involves  not  only  the  pudendal  structure,  lower  part 
of  the  abdomen,  and  the  inner  aspect  of  the  thighs,  but  it  may  extend 
upward  into  the  vagina;  it  may,  indeed,  assume  the  type  of  "  wander- 
ing "  erysipelas,  and  invade  practically  the  entire  surface  of  the  body 
before  it  is  arrested.  The  subcutaneous  infection  may  result  in  the 
formation  of  foci  of  suppuration,  manifesting  themselves  on  the  surface 
of  the  skin  in  the  form  of  large  purulent  blebs,  or,  if  more  deeply  seated, 
as  fluctuating  masses.  The  treatment  should  be  both  local  and  constitu- 
tional. Of  the  local  remedies,  carbolic  acid  in  solution  with  liquid  vase- 
line painted  on  the  surface  with  a  soft  brush  has  the  merit  of  being 
both  convenient  and  effective.  Wliile  the  disease  is  yet  limited  to  the 
vulva,  a  5-per-cent  solution  may  be  employed;  but  when  the  infection 
involves  a  greater  area  a  solution  of  not  more  than  1  per  cent  should 
be  used.  Creolin  and  phenol  are  really  but  milder  forms  of  the  same 
treatment.  Concentrated  solutions  of  salicylic  acid  and  of  sulpho- 
carbolate  of  soda,  respectively,  have  been  employed  subcutaneously 
around  the  circumference  of  the  infected  area.  Comfort  is  derived 
from  any  soft  soothing  application  M'hich  will  protect  the  inflamed 
surface  from  the  air.  Silk  saturated  with  carbolized  liquid  vaseline  or 
with  carbolized  vegetable  oils  is  a  source  of  comfort,  care  being  taken 
to  maintain,  as  nearly  as  possible,  an  equable  temperature  in  the  parts. 
When  suppurations  occur  they  should  be  freely  incised,  the  cavities 
being  treated  antiseptically. 

Erysipelas  as  a  source  of  puerperal  infection  was  first  recognised  by 
Dr.  Oliver  Wendell  Holmes,  his  conclusion  being  based  upon  the  occur- 
rence of  a  number  of  deaths  from  puerperal  fever  in  the  practice  of  a 
physician  whose  finger  was  Ivnown  to  have  been  infected  while  making 
an  autopsy  of  an  erysipelatous  subject.  The  conclusion  thus  arrived 
at  by  the  Autocrat  of  the  Breakfast  Table  has  since  been  confirmed 
by  the  clinical  experience  of  the  world.  The  organism  of  erysipelas, 
isolated  by  Fehleisen,  was  demonstrated  by  Clivio  and  Monti  in  cases 
of  puerperal  peritonitis.  (See  Streptococcus  Erysipelatos,  ante.)  The 
clinical  phenomena  produced  by  this  special  micro-organism  while  the 
infection  is  limited  to  the  vulva  and  vagina  are  not  known,  for  the 


INFECTIONS  OP   TPIE   EXTERNAL   GENITAL   ORGANS  179 

reason  that,  in  puerperal  cases,  the  occurrence  of  this  infection  is  not 
detected  until  it  has  invaded  the  endometrium,  at  which  time  it  is 
readily  demonstrable  in  the  lochia.  As  the  ensuing  essential  clinical 
phenomena  are  manifested  in  connection  with  endometritis,  and  as  the 
treatment  of  this  infection  depends  upon  the  successful  treatment  of 
an  infectious  endometritis,  the  reader  is  referred  to  the  chapter  on 
that  subject. 

Diphtheria  of  the  External  Genital  Organs. — The  inner  surfaces  of 
the  vulva  and  vagina  are  sometimes  the  seat  of  active  diphtheritic  infec- 
tion, which  may  be  either  (a)  primary  or  (b)  secondary.  The  latter 
form,  in  which  the  genital  manifestation  of  the  disease  occurs  sec- 
ondarily to  its  appearance  either  in  the  upper  air-passages  or  other  loci, 
is  the  more  frequent.  Leick,  of  Greifswald,  reported  a  case  of  primary 
diphtheria  involving  the  inner  aspects  of  the  labia  and  extending  into 
the  vagina,  the  characteristic  exudate  yielding  the  Klebs-LoefHer  ba- 
cillus. Eisner  has  recorded  a  case  of  primary  infection  of  the  vagina, 
by  the  same  bacillus,  in  a  puerperal  case.  Infection  of  the  vulva  by 
the  diphtheria  bacillus,  whether  primary  or  secondary,  in  very  young 
subjects  may  cause  noma,  or  circumscribed  gangrene  of  some  part  of 
the  vulvar  structure. 

The  symptoms  of  diphtheria  of  the  vulva  and  vagina  consist  of  an 
initial  chill  followed  by  fever  of  105°  F.  or  more,  rapid  but  feeble  pulse, 
prostration — less  marked,  however,  than  when  the  disease  attacks  the 
respiratory  passages — local  tenderness,  referable  to  the  vulva  or  vagina 
or  both,  which,  upon  inspection,  reveals  the  characteristic  pearly  exu- 
date. The  absolute  diagnosis  depends  upon  the  demonstration  of  the 
Klebs-Loeflfler  bacillus. 

The  treatment  is  both  constitutional  and  topical.  Constitutional 
treatment  consists  in  the  employment  of  the  antitoxine;  the  complete 
disappearance  of  the  membrane  has  been  noticed  in  sixty  hours  fol- 
lowing the  use  of  two  thousand  units  of  antitoxine.  When  the  local 
infection  is  so  virulent  as  to  cause  noma  or  circumscribed  gangrene  of 
the  external  structures,  hot  antiseptic  applications  should  be  made  and 
the  sphacelus,  as  soon  as  well  defined,  should  be  removed,  every  prin- 
ciple of  antisepsis  being  observed  in  the  subsequent  treatment. 

Aphthae,  or  thrush,  is  a  species  of  infection  that  frequently  involves 
the  vulva  and  vagina,  particularly  in  nursing  women.  It  depends  for 
its  occurrence  on  the  Oidium  albicans,  a  vegetative  organism  that  fre- 
quently infests  the  mouths  of  children.  Its  appearance  in  the  external 
genital  organs  does  not  differ  materially  from  that  in  the  infant's 
mouth.  Infection  occurs  in  discrete  areas  elevated  with  an  inflamma- 
tory base  and  covered  by  a  milky  white  exudate.  It  causes  some  local 
pain  with  but  trifling  constitutional  disturbance.  The  treatment  con- 
sists in  thoroughly  cleansing  the  part  with  sterilized  water,  applying, 
subsequently,  a  strong  mercuric  bichloride  solution,  followed  by  a  tam- 
pon saturated  with  boroglyceride.  The  treatment  should  be  repeated 
daily  for  two  or  three  days. 


180  A  TEXT-BOOK  OP  GYNECOLOGY 

Aerogenous  Infection  of  the  Genital  Organs. — Suppuration  attended 
with  gas  formation  has  long  been  recognised.  Eosenbach  studied  these 
jjhlegmons  as  they  occur  in  different  parts  of  the  body  and  described 
what  he  designated  as  the  "  emphysema-bacillus,"  which  he  isolated  on 
cover-slip  preparations.  xVrloing  described  a  gaseous  panophthalmitis 
of  traumatic  origin.  Levy,  in  1891,  isolated  a  short,  fine,  nonmobile  ba- 
cillus from  gas-bearing  pus  of  a  pelvic  abscess.  Other  investigations 
have  been  made  by  William  Koch,  Kitasato,  Wicklein,  Chiari,  and 
Frankel,  the  last  named  of  whom  isolated,  from  gas-producing  pus,  a 
short,  plump,  nonmobile  bacillus  with  rounded  ends  to  which  he  gave 
the  name  Bacillus  phlegmonis  emphysematosus.  While  to  Frankel  credit 
must  be  given  for  originality,  priority  of  discovery  mu.st  be  given  to 
Welch  and  Xuttall  [Medical  Neivs,  September  24,  1893),  who  isolated 
the  organism  which  now  stands  in  the  literature  by  the  name  they 
gave  it — viz.,  the  Bacillus  aerogenes  capsulatus. 

Infection  of  the  vagina,  manifestly  due  to  a  gas  former,  was  first 
described  by  Braun  (ZeitscJirift  fiir  Gesammte  der  Aerzt  im  Wien, 
1861).  The  infection  manifests  itself  by  the  formation  of  cysts,  or, 
more  properly,  air  vesicles  on  the  surface  of  the  vagina  and  on  the 
external  mucous  membrane  of  the  cervix.  These  vesicles  are  close  set, 
glistening,  and  vary  in  size  from  a  millet  to  a  hemp  seed.  When  punc- 
tured, as  a  rule,  nothing  but  air  escapes  from  them;  in  a  few  cases,  how- 
ever, the  cysts  have  yielded  a  slight  amount  of  pale  yellow  nonviscid 
fluid.  Of  twenty-one  cases  collected  by  Herman,  seventeen  were  in 
pregnant  women.  Zweifel  {Archiv  fiir  Gyndhologie)  analyzed  the  gas 
from  these  vesicles  and  found  it  to  be  trimethylamine.  He  made  his 
tests  by  cleansing  the  vagina  and  then  filling  the  speculum  with  test  so- 
lutions under  cover  of  which  the  vesicles  were  punctured.  In  this  way 
he  was  able  to  eliminate  ammonia,  carbonic  acid,  coal  gas,  and  hydric 
sulphide.  The  smell  suggested  the  latter  in  small  quantities.  The 
odour  was  peculiarly  like  that  of  the  plant  Chenopodium  vulvaria,  which 
is  due  to  trimethylamine.  The  treatment  of  this  form  of  infection  con- 
sists in  puncturing  the  vesicles  as  they  appear  and  washing  their  cav- 
ities and  the  vagina  with  antiseptic  solutions.  The  vesicles  show  no 
disposition  to  return  after  being  once  punctured. 

Bilharzia  of  the  vagina  depends  for  its  existence  upon  infection  of 
that  canal  by  the  Distoma  ho3matobium  of  Bilharz,  an  organism  be- 
longing to  the  genus  of  distomatous  parasites  (Cobbold),  and  is  a  cylin- 
drical worm  of  the  order  Trcmatoda.  The  male  is  about  half  an  inch 
long  and  the  female  is  a  little  longer  and  more  slender.  It  abounds  in 
Africa,  and  when  infecting  the  system  it  is  generally  found  in  the  por- 
tal vessels,  and  in  the  veins  of  the  mesentery  and  of  the  urinary  tract, 
causing  profound  constitutional  disturbances,  hematuria,  anaemia,  and 
diarrhoea,  being  among  the  more  prominent  symptoms.  This  parasite 
generally  affects  men  who  work  in  water,  and,  in  the  majority  of  cases, 
produces  serious  local  disturbances  in  the  mucous  membrane  of  the 
bladder,  where  it  causes  single  or  groujDcd  excrescences,  not  unlike  con- 


INFECTIONS  OP  THE  EXTERNAL  GENITAL  ORGANS  181 

dylomata,  with  or  without  pedicles,  and  varying  both  in  shape  and  size. 
The  mucous  membrane  is  thickened  and  the  submucous  connective  tis- 
sue is  hypertrophied;  the  capillaries  are  dilated,  in  some  instances  being 
changed  into  cavities  which  contain  full-grown  specimens  of  the  disto- 
ma.  In  the  interior  of  these  excrescences  numerous  ova  are  found.  It  is 
not  surprising  that  an  organism  which  infests  the  urinary  tract  of  men 
should  find  its  way  into  the  vagina;  and  infections  of  that  canal  by  this 
parasite  are  of  occasional  occurrence.  The  mucous  membrane  becomes 
greatly  hypertrophied  owing  to  papillomatous  developments,  the  ex- 
crescences on  the  interior  of  the  vagina  being  numerous  and  flat-topped, 
and  divided  by  distinct  depressions,  while  occasionally  one  of  them  may 
become  large  and  pedunculated.  The  treatment  consists  in  excising  the 
excrescences,  cauterizing  their  base,  and  treating  the  wounded  surface 
with  bichloride  douches.  It  may  be  necessary,  in  removing  the  larger 
growths,  to  incise  the  mucous  membrane  so  deeply  as  to  render  essential 
the  closure  of  the  wound  by  sutures. 

Chancroid,  or  soft  chancre,  is  a  local,  contagious  ulcer,  which  is 
not  followed  by  infectious,  constitutional  symptoms.  It  occurs  as 
the  result  of  inoculation  from  another  chancroid  and  is  inflammatory 
in  character,  with  destructive  characteristics  which  never  produce 
syphilitic  or  other  systemic  infection.  It  sometimes,  however,  causes 
inflammation  of  neighbouring  lymphatic  glands,  resulting  in  their  sup- 
puration— a  condition  called  chancroidal  lubo.  It  sometimes  becomes 
serpiginous,  spreading  from  its  original  place  to  the  different  parts 
of  the  pudendum,  or  even  to  the  abdominal  walls;  or  it  may  become 
very  destructive,  a  condition  designated  phagedenic  chancroid.  Chan- 
croid is  usually  met  with  in  the  lowest  class  of  society,  where  igno- 
rance and  filth  are  found  together.  It  is  essentially  a  venereal  dis- 
ease, as  it  is  transmitted  chiefly,  if  not  exclusively,  by  the  act  of  sexual 
intercourse.  The  secretion  of  the  chancroid,  or  the  pus  of  the  chan- 
croidal bubo,  is  the  carrier  of  the  contagium.  It  has  been  demonstrated 
that  the  contagious  germs  of  a  soft  chancre  are  contained  in  the 
lymphoid  bodies  or  in  the  pus  cells,  inasmuch  as  the  inoculation  by 
filtered  serum  derived  from  these  sources  produces  only  negative  results. 

One  of  the  characteristics  of  chancroid  is  its  self-inoculability,  by 
which  is  meant  that  one  surface  primarily  inoculated  will,  in  turn, 
inoculate  another  surface  with  which  it  lies  in  contact.  Immunity 
from  such  self-inoculation  is  never  acquired.  The  communication  of 
the  infection  from  one  surface  to  another  requires  the  pre-existence 
of  an  abrasion,  excoriation,  or  small  fissure,  through  which  the  virus 
finds  its  entrance  into  the  derma.  In  some  cases  the  infectious  ele- 
rncnf  finds  its  way  into  the  ducts  of  the  excretory  glands  or  into 
the  lijiir  folliflcs,  ])rodTicing  round  ulcers,  called  follicular  ulcers, 
uliicii  itidiriilc  (lie  clianiicls  1liroiig]i  which  the  virus  entered.  Medi- 
ate contagion  is  more  rare  in  chancroid  than  in  sy])hilis.  Any  article, 
such  as  clothing  or  the  s(!at  of  a  water-ch)set  soiled  with  purulent 
secrotions   from   (;li;iii(i'oids,    it   is   s;iid,  Jimy   coiniimnicate   the   conta- 


182  A  TEXT-BOOK   OP  GYNECOLOGY 

gion^  but  Eavogii  has  never  met  a  case  in  Avhicli  he  could  verify  this 
theory. 

Soft  chancres  may  be  found  in  women  primarily  at  the  ostium 
vaginae,  on  the  fourchette,  the  vestibule,  the  clitoris,  the  labia  majora, 
the  labia  minora,  the  perineum,  the  inner  surface  of  the  thighs,  the 
two  lower  quadrants  of  the  abdomen,  and  around  and  within  the 
margins  of  the  anus;  and  they  appear,  secondarily,  by  self-infection, 
upon  proximal  surfaces,  and  wherever  the  infection  may  be  carried 
to  a  break  in  the  protecting  epithelium.  On  the  labia  they  are  gen- 
erally associated  with  follicular  abscesses,  oedema,  and  frequently  with 
extensive  destruction  of  tissue.  Purulent  secretion  drying  upon  the 
surface  occasions  an  eczematous  apj3earance.  The  terms  exulcerous, 
follicular,  acneform,  eczematous,  erythematous,  serpiginous,  and 
phagedenic,  have  been  applied  to  chancroids  to  distinguish  obvious 
physical  or  clinical  characteristics. 

The  prevalence  of  chancroids  varies  in  different  localities,  being 
more  common  in  cities  on  the  seashore  than  in  those  inland;  and  they 
are  more  prevalent  in  the  crowded  quarters  than  in  the  less  densely 
populated  districts.  Eobert  W.  Taylor  states  that  the  examination  of 
the  puellce  puhlicce  revealed  the  greater  prevalence  of  chancroids 
among  the  women  of  the  lowest  grades,  while  there  was  relatively  a 
greater  prevalence  of  hard  chancre  among  prostitutes  who  were  better 
conditioned.  Eavogii  states  that  relatively  few  cases  of  soft  chancre 
occur,  annually,  in  his  service  at  the  Cincinnati  Hospital,  while  they 
are  very  rare  in  his  private  practice.  He  finds,  also,  that  in  private 
practice  they  are  liable  to  be  of  the  mixed  type.  After  a  few  weeks, 
instead  of  cicatrizing  they  become  hard  and  syphilis  follows,  and  for 
this  reason  he  is  cautious  in  giving  an  early  diagnosis,  particularly 
in  the  case  of  young  subjects.  Eavogii  does  not  accept  the  theory  that 
chancroids  may  be  the  result  of  pus  from  any  other  form  of  ulcera- 
tion associated  with  lack  of  cleanliness;  nor  does  he  believe  that 
chancroid  is  caused  by  syphilis;  but  he  concedes  the  possibility  of 
mixed  infection. 

The  course  of  an  ordinary  chancroid  covers  a  period  of  from  two 
to  three  weeks,  the  time,  however,  being  influenced  by  the  habits  and 
treatment  of  the  patient.  Lack  of  cleanliness,  walking,  and  alcoholic 
drinks,  prolong  the  period.  Tissue  destruction  is  less  extensive  and 
less  rapid  on  the  skin  than  on  the  mucous  membrane.  After  the 
chancroid  reaches  a  certain  point,  there  is  manifested  a  spontaneous 
tendency  to  repair.  The  inflammatory  halo  begins  to  fade,  the 
oedema  disappears,  the  grayish  pseudomembrane  at  the  bottom  of 
the  ulcer  sloughs  off,  revealing  abundant  healthy  granulations.  The 
purulent  secretion  becomes  thicker  and  of  good  colour.  A  ring  of 
epithelium  forms  round  the  edges  of  the  sore,  gradually  encroaching 
upon  its  centre,  until  it  disappears  under  a  film  of  newly  formed 
scar  tissue.  At  this  point,  or,  at  least,  when  near  recovery,  these 
ulcers  may  redevelop,   manifesting  all  their   original   symptoms,   the 


INFECTIONS  OF   THE   EXTERNAL   GENITAL   ORGANS  183 

relapse  being  caused  by  coitus,  alcohol,  or  uncleanliness.  The  appar- 
ently healed  ulcers  may  retain  their  contagiousness  for  a  long  time, 
and  be  capable  of  transmitting  a  disease. 

Bacteriology. — Ducrey  discovered  constant  bacterial  elements  in 
chancroidal  pus.  He  found  in  a  series  of  inoculations  of  chancroid  in 
man,  that  many  microbes,  originally  in  the  pus,  disappeared  from  it, 
but  that  a  peculiar  microbe  remained  constant  and  abundant  so  long 
as  the  pus  retained  its  virulence.  His  observations  were  supported 
by  those  of  XJnna,  Kneftning,  and  others,  all  agreeing  on  the  iden- 
tity of  this  micro-organism.  Ducrey  found  it  in  chancroidal  pus,  and 
Unna  detected  it  in  the  infected  tissues.  It  is  a  rodlike  bacillus, 
from  1.5  to  2  ju,  in  length,  and  from  0.3  to  1  /*  in  breadth,  with  rounded 
ends.  It  has  a  tendency  to  form  chains  (strepto-bacillus)  and  to  become 
agglomerated  in  masses.  In  the  pus  it  occurs  singly,  but  in  the  tissues 
it  is  always  in  chain  form.  It  has  been  found  almost  constantly  in 
chancroid;  it  is  stained  by  carbolic-fuchsin,  and  by  gentian  violet,  and 
is  decolourized  by  Gram's  method.  Although  it  is  a  pus  bacillus  it  is 
characteristic  of  soft  chancre,  because  it  has  not  been  found  under  other 
conditions. 

Pathology. — Chancroidal  virus  begins  its  activity  as  soon  as  it  finds 
an  infection  atrium,  through  which  it  gains  access  into  the  subepi- 
thelial layer;  the  ulceration  on  the  surface  of  the  skin  appears  later, 
but  is  more  rapid  in  development  on  the  vaginal  mucosa.  As  a  rule 
the  virus  manifests  its  activity  by  developing  within  from  twenty-four  to 
forty-eight  hours  a  small  pustule,  surrounded  by  an  intensely  red  inflam- 
matory halo.  This  stage,  especially  in  the  mucous  membrane,  is 
soon  replaced  by  the  characteristic  ulceration,  round  or  oval  in 
shape,  according  to  the  conformation  of  the  parts;  thus,  when  de- 
veloped within  a  fold,  it  may  take  on  a  linear  appearance,  while  on 
the  inner  aspects  of  the  labia  majora  the  ulcers  may  coalesce  and  be- 
come irregular.  But  wherever  the  chancroid  occurs,  or  whatever  its 
shape,  the  edges  are  sharply  cut  as  if  the  disk  could  be  readily 
punched  out.  The  bottom  of  a  chancroid  is  uneven,  and,  in  the  begin- 
ning, is  covered  with  a  kind  of  diphtheroid  membrane  consisting 
of  necrotic  tissue.  The  ulcer  exudes  abundant,  thin,  purulent  secre- 
tion, sometimes  of  a  rusty  colour;  the  underlying  cellular  tissue  is 
sometimes  oedematous — particularly  when  the  inflammation  is  intense, 
in  which  case  the  soft  chancre  manifests  firmer  consistence  when 
taken  between  the  fingers,  which  fact  must  not  mislead  the  practi- 
tioner into  mistaking  the  case  for  one  of  syphilis. 

The  diagnosis  of  chancroids  may  be  confusing  in  the  earlier 
stages.  They  may  then  be  mistaken  for  herpes,  but  the  difference 
will  be  detectable  by  a  careful  examination  of  the  lesions.  Vesicles, 
a  nonulceratcd  surface  even  when  broken,  smooth  edges,  and  the 
coalescence  of  vesicles,  are  features  of  herpes.  Sometimes  chancroids 
are  mistaken  for  syy)hilitic  mucous  patches;  the  development,  size,  in- 
diiijilioji,    pffuliiir   colour,   elevation   of  the   edges,   and   symptoms   of 


184  ^   TEXT-BOOK  OF  GYNECOLOGY 

syphilis,  will,  however,  enable  physicians  to  distinguish  between  the 
two  conditions.  If  doubt  still  remains,  recourse  may  be  had  to  the 
crucial  test  of  self-inoculation. 

The  prognosis  of  chancroids  is  less  favourable  in  women  than 
in  men.  The  conformation  of  the  parts,  the  difficulty  of  cleansing 
them  and  of  retaining  dressings,  the  presence  of  urine  and  of  the 
menstrual  fluid,  are  all  barriers  to  a  speedy  cure.  Suppurative  adenitis 
or  buboes  prolong  the  treatment.  Phagedena,  fortunately  rare,  is 
generally  promptly  overcome.  In  cases  occurring  in  drunkards  of 
lowered  vitality,  a  guarded  prognosis  should  be  given. 

The  treatment,  to  be  effective,  must  be  based  upon  the  principle 
of  cleanliness.  Eavogli  secures  this  in  his  hospital  service  by  having 
the  parts  washed  three  times  a  day  with  hydrogen  peroxide,  dusted 
with  iodoform  powder,  and  covered  Avith  iodoform  gauze.  Cure  is 
generally  very  prompt  and  free  from  complications,  no  buboes  having 
developed  in  his  wards.  In  rapidly  progressive  chancroids,  cauteri- 
zation by  carbolic  acid  or  nitric  acid  should  be  practised.  The  sur- 
face should  be  first  rendered  insensitive  with  a  5-per-cent  solution 
of  cocaine  hydrochloride.  Care  should  be  taken  to  protect  the  neigh- 
bouring parts  from  the  action  of  the  caustics.  The  use  of  carbolic 
acid  is  followed  by  a  little  secretion,  and  is  less  painful  than  nitric 
acid  which  causes  sharp  inflammatory  reaction.  After  cauterization 
the  ulcer  is  treated  like  any  other  granulating  surface.  Iodoform  in 
private  practice  is  objectionable  because  of  its  odour.  lodol,  europhen, 
bismuth  subiodide,  have  all  been  tried  and  discarded  by  Eavogli,  who 
still  uses  aristol  but  deems  it  inferior  to  iodoform.  Gaylord  has  used 
with  success  a  10-  to  40-per-cent  solution  of  formalin  as  an  escharotic. 
Strong  applications  of  this  kind,  however,  have  been  generally  aban- 
doned since  the  advent  of  iodoform.  A  6-  to  8-per-cent  solution  of 
sulphate  of  copper  stimulates  granulation.  If  the  ulcer  is  sluggish  in 
healing,  it  may  be  curetted.  A  well-regulated  diet,  improved  hygiene, 
stimulants  and  tonics,  are  indicated  in  old  run-down  cases.  Opiates 
are  sometimes  needed  for  pain,  although  hot  water  containing  a  little 
potassium  permanganate  or  mercury  bichloride,  used  in  compresses, 
may  be  sufficient  to  allay  the  pain  and  to  change  an  unhealthy  to  a 
healthy  surface. 

Hard  chancres  in  women  are  very  frequent,  their  course  is  irregu- 
lar, and  their  diagnosis  sometimes  difficult.  In  some  cases  the  chancre 
is  so  small  and  ephemeral  that  it  is  often  overlooked;  in  others  it 
is  very  pronounced,  but  on  account  of  the  associated  inflammatory 
conditions,  its  exact  nature  is  more  or  less  obscured.  In  women,  the 
characteristic  induration  of  chancre  is  less  pronounced  than  in  men; 
occasionally,  when  located  around  the  fourchette,  it  produces  a  hard 
thick  cicatrix  which  may  last  for  many  months.  The  examination 
of  the  genitalia  in  women  is  sometimes  difficult  on  account  of  the 
conformation  of  the  parts,  although  in  all  cases  it  should  be  made 
with  thoroughness.     Chancres  may  be   single   or  multiple,   only  one 


INFECTIONS  OF   THE  EXTERNAL   GENITAL   ORGANS  185 

being  found  in  the  majority  of  cases.  For  clinical  purposes,  chancres 
in  women  have  been  divided  into  (1)  superficial  or  chancrous  erosion; 
(2)  scaling  papule;  (3)  elevated  papule,  or  ulcus  elevatum;  (4)  incrusted 
chancre;  (5)  indurated  nodules;  (6)  diffused  exulcerated  chancre. 

(1)  Superficial,  or  chancrous  erosion  is  the  form  most  frequently 
met  with  in  women.  It  is  difficult  to  recognise  in  its  earliest  stages; 
it  is  always  found  on  the  surface  of  the  mucous  membrane,  begin- 
ning as  a  red  spot  somewhat  deeper  in  colour  than  the  mucous  mem- 
brane itself.  It  is  liable  to  pass  without  notice,  so  that  when  first 
seen  by  the  physician  it  is  already  deprived  of  its  epithelium  and 
manifests  incipient  ulceration.  When  it  is  seated  on  smooth  sur- 
faces like  the  labia  it  is  easily  recognised,  but  when  it  is  on  the 
fourchette  or  within  the  ostium  vaginse  it  is  not  easily  discovered.  ,The 
chancre  is  of  red  colour,  round,  with  a  smooth  surface,  from  which 
oozes  a  thin  serous  secretion  that  assumes  the  appearance  of  true 
pus  only  in  the  presence  of  active  inflammation.  In  these  chancres, 
the  induration  is  only  superficial,  of  that  kind  which  Fornia  called 
chancre  parchemine.  The  diagnosis  of  this  form  of  chancre  is  not 
difficult  when  due  attention  is  given  to  the  foregoing  appearances.  The 
exact  character  of  the  trouble  is  established  in  the  course  of  a  few 
days  when  the  lymphatic  glands  of  the  groin  become  involved.  The 
course  of  this  kind  of  chancre  is  rather  short;  it  undergoes  speedy 
involution,  which  accounts  for  the  fact  that  constitutional  symptoms 
of  syphilis  are  manifested  in  some  women  in  whom  we  are  not  able 
to  find  the  initial  sore.  In  many  cases,  however,  after  the  disappear- 
ance of  the  chancre,  there  remains  on  the  area  that  it  occupied,  a  kind 
of  red  spot,  very  persistent,  and  lasting  at  times  for  months.  This 
chancrous  erosion,  especially  when  located  on  the  vulvar  lips,  produces 
a  kind  of  chronic  oedema  of  the  underlying  tissues,  and  sometimes 
of  all  the  pudendal  structures;  it  lasts  frequently  after  the  chancre 
has  completely  healed.  When  the  primary  ulcer  is  seated  on  the 
fourchette  it  assumes  the  typical  induration  of  a  hard  chancre,  pre- 
senting a  raw-beef  appearance  characteristic  of  the  initial  syphilitic 
lesion.  (2)  The  scaling  papule  may  appear  on  the  skin  of  the  labia 
majora  and  of  the  labia  minora  as  the  initial  syphilitic  lesion.  It 
is  a  small,  dull-reddish  papule,  slightly  elevated.  It  develops  into 
an  elevation  of  the  skin,  has  a  purplish  brown  colour,  sharply 
defined  edges,  and  in  size  varies  from  that  of  a  split  pea  to  that  of 
a  quarter  of  a  dollar.  It  is  round  or  oval  according  to  the  shape 
of  the  parts  where  it  is  located,  and  is  firm,  hard,  and  resistant  to 
the  touch.  It  is  usually  single,  sometimes  double,  and  gradually  loses 
its  epithelium,  becoming  ulcerated  and  incrusted,  when  it  is  called 
an  ecthymatous  chancre.  (?>)  The  elevated  papule,  or  ulcus  elevatum, 
begins  as  a  chancrous  erosion  with  hyperplastic  infiltration,  and  grows 
1o  a  considerable  size.  It  is  round  or  oval,  deep  red  in  colour,  and 
has  a  smooth,  velvety  surface,  fiat  or  concave  with  distinctly  elevated 
edges,  and  discharges   a   thin   serous  fluid.      Ii'riijii  ion    from   walking 


186  ^  TEXT-BOOK  OP  GYNECOLOGY 

or  from  uncleanliness  may  provoke  inflammation,  causing  a  pro- 
nounced oedema  of  the  labium  on  whicli  it  is  seated.  Careful  pal- 
pation will  reveal  a  slight  induration,  parchmentlike  in  character.  This 
condition  is  essentially  chronic,  lasting  many  weeks,  resolving  slowly, 
leaving  a  deep  red  spot  which  is  replaced  by  a  sear.  (4)  Incrusted 
cliancre  affects  the  cutaneous  surface  of  the  pudendum,  beginning  as  a 
chancrous  erosion  or  as  an  indurated  nodule,  and  speedily  developing 
a  kind  of  film  of  a  light,  greenish,  creamy  tint,  or,  at  other  times, 
of  a  brownish  red  necrotic  character.  (5)  The  indurated  nodule  is 
rather  rare  in  women  and  is  found  where  the  skin  and  mucous  mem- 
brane join  each  other.  It  manifests  itself  as  a  sharply  circumscribed 
mass  of  indurated  tissue  with  a  narrow  base  and  sloping  edges.  (6) 
The  diffiused  exulcerated  chancre  is  found  in  women  of  the  lower  class; 
it  begins  as  a  chancrous  erosion,  grows  to  an  ulcus  elevatum,  and 
then  spreads  over  an  extensive  area.  It  has  an  ulcerated  and  un- 
even surface,  deep  red  in  colour,  but  only  slightly  painful,  although 
frequently  associated  with  oedema  of  the  part  on  which  it  is  developed. 

The  hacterial  origin  of  syphilis,  although  very  probable,  has  not 
been  demonstrated.  The  analogy  between  syphilis  and  other  diseases  of 
known  bacterial  origin  prompts  the  belief  that  the  various  phenomena 
of  the  disease  depend  upon  a  bacillus,  not  yet  isolated,  and  its  toxines. 

The  pathologic  changes  occurring  in  indurated  chancre  are  of  an 
inflammatory  character,  and  are  accompanied  in  any  stage  of  syphilis 
with  a  persistent  involvement  of  the  blood  vessels;  an  infiltration  of 
small  round  cells  associated  with  those  of  larger  size,  and  polyhedral 
in  form,  occurs  in  the  meshes  of  the  connective  tissue  surrounding  the 
blood  vessels.  There  is  a  constant  tendency  to  the  production  of  new 
connective  tissue,  especially  in  the  initial  chancre,  and  again  in  the 
later  tertiary  stage  as  manifested  in  the  nervous  system.  The  peri- 
vascular changes  and  the  infiltration  of  the  tissues  beyond  the  chancre 
are  the  most  important  features  of  the  initial  sore.  The  lymph  spaces 
are  readily  afi^ected  with  the  peculiar  infiltration,  the  virus  speedily 
travelling  through  this  channel  to  the  inguinal  glands.  The  peripheral 
perivascular  lymph  spaces  are  infected  by  the  time  the  chancre  makes 
its  appearance;  and  the  first  halt  in  the  march  of  the  virus  is  shown 
by  the  swelling  and  induration  of  the  inguinal  glands.  Microscopically, 
a  well-developed  chancre  reveals  a  seminecrotic  mass  of  small  sphe- 
roidal cells  which  constitute  the  bulk  of  the  ulcer,  circumvallated  by 
a  zone  of  oedema  and  a  cellular  infiltration  of  the  papillary  layer  of 
the  derma.  This  oedema  acts  as  a  wall  to  protect  the  surrounding 
healthy  tissues  from  invasion.  The  virus,  having  entered  the  lym- 
phatics, passes  from  one  gland  to  another  until  it  reaches  the  general 
circulation.  This  occurrence  marks  the  transition  from  the  secondary, 
or  incubation  period,  and  the  disease  breaks  out  in  the  ordinary  form 
of  roseola  with  all  the  accompanying  symptoms  of  chlorosis,  neuralgia, 
syphilitic  fever,  etc. 

The  female  genitals,  like  any  other  part  of  the  integument,  may 


INFECTIONS  OF  THE   EXTERNAL  GENITAL   ORGANS  187 

show  every  kind  of  eruption  which  results  from  the  two  morbid  pro- 
cesses of  hypersemia  and  infiltration.  The  hyperemia  is  mostly  found 
in  the  early  period  of  syphilis  in  the  erythematous  syphilides;  the 
infiltration  is  always  more  advanced  in  the  later  stages.  In  the  early 
eruptions,  however,  a  slight  cell  infiltration  is  always  present,  giving 
rise  to  patches  and  nodules.  In  this  stage  of  syphilis,  Eavogli  has 
repeatedly  found  a  kind  of  infiltration  of  the  skin  of  the  labia  majora 
and  labia  minora,  just  at  their  free  edges,  showing  the  epidermis  slightly 
abraded  and  intermingled  with  superficial  erosions;  besides  this  slight 
thickening  of  the  skin,  the  patches  show  a  kind  of  dirty  yellowish 
colour,  and  are  accompanied  with  itching.  Mucous  patches  or  con- 
dylomata lata,  are  quite  often  found  on  the  external  genitals  of  women, 
during  the  first  two  years  of  the  course  of  syphilis;  this  eruption  is 
characteristic  of  syphilis,  and  when  discovered  settles  all  doubt  relative 
to  the  diagnosis.  Mucous  patches,  on  account  of  their  abundant  secre- 
tion, are  the  most  dangerous  eruption  for  the  transmission  of  syphilis. 
Eavogli  is  of  the  opinion  that  most  cases  of  syphilis  are  communicated 
by  mucous  patches.  They  are  found  on  the  mucous  membranes  and 
on  proximal  surfaces  of  the  skin  which  are  continually  moistened  by 
perspiration.  They  begin  on  the  skin  as  flat  elevations,  circular  or  dis- 
coid in  form,  and  of  different  sizes,  showing  a  depression  in  the  centre 
with  elevated  borders;  the  epidermis  in  the  centre  is  macerated  by 
the  moisture  and  is  transformed  into  a  grayish  pellicle.  This  is  soon 
cast  off,  leaving  a  plaque  of  a  raw  flesh-coloured  appearance.  This 
plaque  secretes  abundant  serum,  which  soon  becomes  altered  and 
causes  an  offensive  smell,  and  by  irritating  the  skin  induces  intertrigo. 
Eavogli  has  observed  a  kind  of  contagiousness  in  these  patches,  mani- 
fested by  the  development  of  similar  lesions  on  proximal  cutaneous 
or  mucous  surfaces.  They  assume  a  variety  of  appearances,  accord- 
ing to  location  and  the  local  conditions  to  which  they  are  subjected. 
On  account  of  the  presence  of  urine,  perspiration,  etc.,  they  may  de- 
velop superficial  ulceration,  manifested  by  an  abundance  of  offensive, 
purulent  secretion.  As  a  result  of  persistent  irritation,  the  patches 
may  become  uneven  with  a  verrucous  aspect,  caused  by  hypertrophy 
of  the  papillae  of  the  derma,  a  hypertrophy  which  sometimes  assumes 
a  vegetating  character  (condylomata  lata).  These  different  appearances 
of  mucous  patches  have  caused  authors  to  classify  them  as  diphtheroid, 
ulcerative,  vegetative,  or  hypertrophic.  They  are  either  round  or  oval 
in  shape,  according  to  the  part  upon  which  they  are  located;  some- 
times they  appear  like  ulcerated  rhagades  around  the  ostium  vaginas 
or  between  the  anal  folds.  On  the  mucous  membranes,  mucous  patches 
have  a  kind  of  grayish  appearance  with  marked  edges  slightly  ex- 
coriated in  the  centre.  The  chronological  period  of  mucous  patches 
is  the  secondary  stage  from  its  beginning  to  its  end.  Eavogli 
(Monatshefle  fiir  praJdisclie  Dermatologie,  1893)  observes  that  it  is  not 
rare  to  see  patches  on  the  tongue  and  in  the  mouth  of  syphilitic 
patients  after  four  or  five  years  following  the  ])riinary  infection,  and 


188  A  TEXT-BOOK   OF  GYNECOLOGY 

in  patients  who  are  already  manifesting  tertiary  symptoms.  These 
lesions  are  sometimes  the  most  stubborn  manifestations  of  syphilis,  as 
they  show  a  tendency  to  frequent  recurrence.  When  not  properly 
treated,  they  may  become  hypertrophic,  forming  papillomatous  masses 
which  may  persist  for  a  long  time.  They  usually  disappear  by  a  pro- 
cess of  superficial  ulceration  and  without  leaving  a  scar.  The  anatomo- 
pathologic  lesions  of  mucous  patches  consist  in  hypertrophy  of  the 
papillse,  and  in  abundant  infiltration  of  cells  throughout  the  papil- 
lary layer  and  the  corium.  The  mucous  layer,  of  the  epidermis  is 
also  affected,  showing  a  proliferation  of  the  cells,  and  a  granular 
change  of  their  protoplasm  that  gives  to  the  cells  a  peculiar  appear- 
ance. In  the  ulcerated  patches  this  becomes  obscure.  On  account 
of  the  dusky  appearance  of  the  infiltrated  papillae,  the  mucous  layer 
in  many  points  being  absent,  and  the  tips  of  the  papilla?  mutilated  by 
the  ulcerative  process,  mucous  patches  when  once  seen  and  identified 
will  always  be  recognised.  There  can  be  no  doubt  that  they  are  an 
exclusive  form  of  constitutional  syphilis. 

We  have  already  spoken  of  the  acuminated  cond3domata,  which  are . 
nonsyphilitic  manifestations,  and  we  have  pointed  out  the  charac- 
teristics which  distinguish  them  from  the  condylomata,  or  mucous 
patches.  It  is  possible  to  make  a  mistake  only  in  cases  of  hypertrophic 
or  vegetative  mucous  patches,  but  the  absence  of  the  pedicles,  the 
characteristic  ulceration,  the  abundant  sero-purulent  secretion,  and 
the  accompanying  antisyphilitic  symptoms,  should  be  sufficient  points 
of  difference  to  establish  the  true  diagnosis. 

Treatment. — It  is  beyond  doubt  that  in  order  properly  to  treat 
mucous  patches,  a  general  antisyphilitic  treatment  must  be  adminis- 
tered. The  choice  of  the  antisyphilitic  remedies  is  subject  to  the  con- 
dition of  the  patient,  to  the  period  of  syphilis,  and  so  forth;  and  it 
would  be  entirely  out  of  place  to  enter  here  into  such  a  difficult  and 
intricate  question.  The  mucous  patches  require  local  treatment. 
Local  treatment  in  a  great  many  cases  consists  in  the  observance  of 
the  rules  of  cleanliness.  The  best  treatment,  in  Ravogli's  opinion,  for 
mucous  patches,  is  to  wash  the  surface  well  with'  an  antisyphilitic 
solution  of  mercury  bichloride,  1  to  2,000,  and,  after  a  while,  to  dry 
and  powder  them  with  calomel.  In  some  cases  the  mucous  patches 
are  extremely  stubborn,  with  a  tendency  to  ulceration  and  hypertrophy, 
and  in  these  cases  it  is  necessary  to  use  caustics.  The  application 
of  a  4-per-cent  solution  of  acid  nitrate  of  mercury  produces  a  super- 
ficial cauterization,  and  we  may  be  sure  that  after  touching  the 
mucous  patches  two  or  three  times  with  this  solution  they  will  readily 
heal.  Sometimes  the  mucous  patches  resist  the  application  of  the 
solution  of  acid  nitrate  of  mercury,  and  in  these  cases  it  is  necessary 
to  resort  to  stronger  caustics;  then,  nitric  acid  in  full  strength  is 
useful  for  the  destruction  of  these  patches.  The  application  of  salves 
or  plasters  to  mucous  patches  is  not  to  be  recommended,  because  they 
are  found  where  the  skin  forms  folds  and  is  macerated  by  the  per- 


INFECTIONS   OF   THE   EXTERNAL   GENITAL   ORGANS  189 

spiraticn;  it  is  better,  therefore,  to  use  antiseptic  Lathing  and  the 
ajjplication  of  dry  powder,  which  will  prevent  the  accumulation  of 
the  perspiration. 

Late  Syphilitic  Ulcers  of  the  Female  Genitals. — Syphilitic  ulcers 
of  the  vulva  were  studied  in  1849  by  Huguier,  in  his  article  on  Esthio- 
mene,  or  Dartre  Rongeante  de  la  region  vulvo  anale,  Paris,  1849,  and 
by  Matthews  Duncan  in  the  Edinburgli  Medical  Journal,  July,  1881. 
In  the  venereal  ward  of  the  Cincinnati  Hospital,  Eavogli  has  had 
occasion  to  observe  a  great  many  cases  of  extensive  and  deep  ulcers 
of  the  vulva  in  dissolute  women  who  have  been  admitted  into  that 
institution.  He  supports  the  opinion  of  Hyde  in  denying  that  those 
ulcers  of  the  vulva  have  anything  to  do  with  lupus  vulgaris,  and  thinks 
that  there  can  be  no  doubt  that  the  women  have  been  affected  with 
syphilis.  He  admits  that  the  extreme  destruction  of  the  external  geni- 
tals of  women  which  are  occasionally  observed  may  be  due,  not  to 
syphilis  alone,  but  probably  to  syphilis  in  connection  with  tuberculosis; 
and  he  remembers  one  case  in  his  service  in  which  a  large  and  deep 
ulcer  had  destroyed  part  of  the  labia  minora  and  part  of  the  entrance 
of  the  vagina.  The  woman  died,  and  at  the  post-mortem  the  peri- 
neum was  found  to  be  studded  with  tubercles.  Usually,  these  ulcers 
are  found  in  weak  patients,  with  a  system  run  down  from  misery 
and  debauchery.  The  ulcers  are  always  seated  on  a  strong  and  thick 
induration  which  is  confined  to  one  or  both  labia.  This  infiltration 
sometimes  extends  to  the  mons  veneris,  and  may  also  spread  downward 
to  the  perineal  tissues.  It  is  accompanied  by  a  kind  of  hypertrophy 
which  is  felt  deeply  situated  in  all  the  tissues.  On  these  indurated 
places,  ulcers  are  found  which  are  deep  and  destructive.  One  or  both 
labia  may  be  destroyed.  Sometimes,  when  the  ulceration  affects  the 
perineum,  the  destruction  may  extend  to  the  anus  producing  altera- 
tion of  its  function.  The  edges  of  these  ulcers  slope  to  the  bottom, 
which  is  red  or  grayish  from  necrotic  detritus,  without  a  tendency 
to  the  formation  of  healthy  granulations.  The  destruction  once  begun 
goes  on  very  rapidly,  and  it  is  a  difficult  task  to  stop  its  ravages.  Says 
Eavogli:  "  In  my  experience  I  have  found  this  form  of  vulvar  syphilitic 
ulcers  more  frequent  in  the  negro  race  than  in  the  white  race.  The 
date  of  infection  from  syphilis  was  from  six  to  twelve  years.  Ko 
enlarged  glands  could  be  found  in  the  groins  or  in  the  cervical  region, 
yet,  in  many  of  these  women,  deep  scars  could  be  found  on  the  legs, 
witnesses  of  progressed  gummata,  and  roughness  of  the  tibia  could 
be  found,  showing  progressed  specific  periostitis.  These  ulcers  are 
the  result  of  late  syphilis.  They  are  the  result  of  gummatous  infil- 
tration, but  there  is  no  doubt  that  the  general  condition  of  these 
patients  has  a  great  flea]  to  do  with  the  virulence  of  syphilis." 

'Jlic  prognosis  of  tlicse  ulcers  must  be  given  with  great  reserve. 
There  are  two  principal  elements  for  the  production  of  the  ulcers: 
First,  advanced  malignant  syphilis;  secondly,  weakness  of  the  general 
system. 


190  A   TEXT-BOOK  OF   GYNECOLOGY 

The  treatment  consists,  first,  in  improving  the  general  system  with 
good  diet,  tonics,  and  better  surroundings.  Antisyphilitic  treatment 
consists  mostly  in  the  administration  of  potassium  or  sodium  iodide. 
Mercurials  can  scarcely  be  recommended  on  account  of  the  weak  and 
poor  condition  of  the  patients.  Beneficial  results  follow  applications 
of  a  solution  of  mercury  bichloride,  1  to  2,000,  and  then  covering 
the  ulcerated  and  infiltrated  surface  with  the  emplastrum  hydrargyri, 
which,  producing  an  abundant  suppuration,  in  a  short  time  causes  a 
sloughing  out  of  all  the  detritus  from  the  bottom  of  the  ulcers.  In 
the  same  way,  the  application  of  the  emplastrum  hydrargyri  helps  a 
great  deal  toward  the  absorption  of  the  infiltration  and  oedema  which 
form  the  base  of  these  vulvar  syphilitic  ulcers.  The  washing  with 
peroxide  of  hydrogen  and  the  application  of  powdered  iodoform  have 
also  given  very  good  results,  but  only  in  later  stages,  when  the  em- 
plastrum hydrargyri  had  already  diminished  the  infiltration.  The 
curette  has  been  used  in  cases  where  the  surface  has  been  covered 
with  abundant  ill-natured  granulations.  But  with  this  exception, 
there  is  but  little  need  for  the  curetting  of  such  ulcers.  The  applica- 
tion of  strong  caustics,  such  as  nitric  acid  and  the  actual  cautery, 
has  been  tried  only  in  those  cases  in  which  the  destructive  process 
had  taken  wide  proportions.  It  is  seldom  necessary  to  resort  to  these 
means,  particularly  when  good  results  are  realized  by  the  emplastrum 
hydrargyri. 


CHAPTEE    XVII 

DISEASES   OF   THE   SKIN   OF   THE  FEMALE   GENITALS 

Intertrigo — Erythema — CEdeina — Eczema — Folliculitis — Herpes  progenitalis — Pru- 
ritus— Parasitic  affections — Atrophy  (Kraurosis) — Vulvar  adhesions. 

The  skin  of  the  genitals  of  the  woman  is  subject  to  all  the  diseases 
that  are  met  with  in  the  general  integument,  and,  on  account  of  their 
anatomical  structure  and  position,  some  affections  are  more  frequently 
found  here  than  in  other  regions. 

Intertrigo. — This  common  affection  is  usually  found  in  fleshy 
women.  It  is  produced  by  the  apposition  of  the  surfaces  of  the  skin  of 
the  thighs  with  each  other  and  with  the  external  portion  of  the  labia 
majora,  and  is  a  result  of  friction.  Under  these  circumstances  perspira- 
tion is  very  abundant,  and  it  macerates  the  epidermis  and  causes  an 
inflammation  of  the  skin,  which  in  the  beginning  is  limited  to  the  de- 
gree of  a  simple  erythema,  but,  continuing,  reaches  the  degree  of  a  true 
eczema.  Indeed,  in  the  beginning,  the  surface  of  the  inguino-crural 
fold  and  of  the  labia  is  red  and  moist,  and  the  epidermis  appears  slightly 
macerated.  An  itching  and  burning  sensation  is  associated  with  the 
affection.  If  promj)tly  treated  the  skin  returns  to  the  normal  condition 
in  a  short  time.  If  the  affection  is  allowed  to  continue,  then,  on  account 
of  the  profuse  perspiration  and  of  its  chemical  changes,  associated  with 
impurities  and  uncleanliness,  the  epidermis  is  deeply  macerated,  the  sur- 
face is  excoriated,  oozing  a  serum  which  starches  the  linen,  and  the 
patient  can  scarcely  move  on  account  of  the  pain  produced  by  the 
motion  on  the  inflamed  skin.  Although  the  affection  is  called  eczema 
intertrigo,  Eavogli  does  not  consider  it  a  true  eczema.  Eczema  may  be 
the  consequence  of  the  intertrigo,  just  as  it  may  follow  any  other  irrita- 
tion of  the  skin. 

Vulvar  intertrigo  is  caused  by  gonorrhoea,  syphilis,  or  the  accumula- 
tion of  nonspecific  but  irritating  secretions,  in  the  cutaneous  folds  of 
the  puflenda  and  groins.  The  large  quantity  of  sero-purulent  secre- 
tion oozing  out  of  the  vagina  in  cases  of  gonorrhoea,  moistens  the  skin 
of  the  genitals  and  of  the  thighs,  and  by  its  irritating  qualities  causes 
intertriginous  eruption.  This  intertrigo  is  also  found  in  patients  who 
observe  strict  cleanliness.  In  women  neglectful  of  the  principles  of 
hygiene  the  intertrigo  assumes  a  mnch  more  aggravated  form.  In 
the  first  case  the  affection  is  limited  to  the  front  part  of  the  geiiitals, 
Inhiii  tiinjoTM,  l;ilji;i  iiiinor;i,  iitid  clitoris  with  its  prepuce,  as  a  result  of 

191 


192  A   TEXT-BOOK  OF   GYNECOLOGY 

the  contact  of  the  gonorrhoeal  fluid  on  the  skin.  In  the  second  case  in- 
tertrigo is  spread  more  on  the  internal  surface  of  the  thighs  and  of  the 
labia  niajora  in  the  fossa  genito-cruralis,  in  consequence,  not  merely  of 
the  presence  of  the  purulent  secretion,  hut  also  of  the  friction  of  the  two 
surfaces  of  the  skin,  which  become  macerated  by  the  purulent  secretion, 
perspiration,  and  other  impurities.  Intertrigo  in  these  cases  is  acute, 
the  surface  of  the  aft'ected  skin  is  red  and  somewhat  swollen;  the 
epidermis  is  macerated,  giving  it  a  whitish,  soggy  ajDpearance;  abrasions 
and  small  rhagades  are  formed  on  the  labia  majora,  in  an  oblique  direc- 
tion toward  the  fossa  genito-cruralis;  the  surface  is  always  moist  from 
the  discharge  of  serum,  wliich,  together  with  the  gonorrhoeal  secretion 
and  the  perspiration,  jjroduces  an  offensive  smell.  A  burning  sensation 
accompanies  the  course  of  the  affection,  and  motion  makes  it  so  painful 
that  the  woman  can  scarcely  Avalk. 

Another  form  of  intertrigo,  more  chronic  in  form  but  occurring 
under  the  same  circumstances,  was  recently  described  by  L.  Brocq  and 
Leon  Bernard  (Annales  de  dermafologie  et  de  sypliiligraphie,  1899, 
fasc.  1,  3).  It  is  limited  to  the  genito-crural  fossa,  and  when  the  woman 
is  placed  in  the  position  used  for  the  speculum  examination,  it  appears 
like  a  triangle  with  the  base  at  the  fossa  and  the  apex  downward  on  the 
upper  lateral  side  of  the  thighs.  The  skin  is  of  an  intensely  dark-red 
colour,  showing  deep  furrows  in  an  oblique  direction,  and  between  them 
follicles  can  be  seen.  The  pigmentation  is  very  deep,  due  partly  to  the 
inflammatory  process  and  partly  to  tJie  chromatogenous  condition  of 
these  regions.  A -kind  of  small,  flat,  papillary  growth  can  be  seen  on 
the  surface  like  a  lichenization,  which  is  due  to  a  proliferation  of  the 
connective  tissues  in  the  papilla  with  some  hypertrophy  of  the  epider- 
mic lavers. 

The  pathoUxjii  of  this  afl^ection  is  limited  to  the  epidermis  and  to  the 
superficial  layer  of  the  derma.  They  are  the  same  as  are  found  in 
any  other  inflammatory  disease  of  the  skin,  hyperemia,  overfilling  of 
the  blood  vessels,  which  is  the  cause  of  the  inflammatory  redness,  and 
swelling.  In  consequence,  after  increased  pressure  in  the  blood  vessels, 
some  exudation  of  serum  and  of  the  white  corpuscles  of  the  blood  takes 
place  through  the  walls  of  the  blood  vessels.  The  small  round  inflam- 
mator}^  cells  and  the  white  corpuscles  of  the  blood  infiltrate  the  papil- 
lary layer,  and  so  increase  the  nutrition  of  their  connective  tissues. 
The  epidermic  cells  are  macerated  by  the  presence  of  the  exudation,  and 
the  horny  laj^er  is  easily  detached  by  the  other  epidermic  layers,  and  in 
this  way  excoriations  are  formed.  On  the  other  hand,  when  the  inflam- 
matory process  lasts  for  a  long  time  the  papillae  become  infiltrated  with 
cells,  and  their  connective-tissue  corpuscles  may  increase  in  their  nutri- 
tion and  proliferate,  producing  small  flat  papillary  warts  as  a  conse- 
quence of  the  irritation. 

The  diagnosis  of  intertrigo  by  pathologic  alterations  from  eczema 
and  dermatitis  is  an  impossibility.  Bavogli,  in  reply  to  the  ques- 
tion whether  this  affection,  being  of  an  inflammatory  character,  is 


DISEASES  OF   THE  SKIN  OP  THE   FEMALE   GENITALS        193 

to  be  classified  as  an  eczema  or  a  dermatitis,  replies:  It  is  a  question  of 
degree;  it  progresses  from  a  pale  rose-red  colour  to  a  deep  reddish-violet 
colour.  From  a  scarcely  perceptible  swelling  it  may  attain  a  thick  and 
pronounced  oedematous  condition,  and  in  the  same  way  there  can  be  a 
thin,  serous,  scanty  discharge,  while  in  other  cases  an  abundant,  copious 
discharge  exudes,  which  wets  the  linen  of  the  patient.  He  believes, 
therefore,  that  the  name  intertrigo  is  well  adapted.  It  gives  the  idea  of 
the  affection  as  the  result  of  the  friction  of  two  cutaneous  surfaces,  and 
of  the  possibility  of  ciiring  it  in  a  short  time  by  preventing  the  contact 
of  the  cutaneous  surface.  It  is  of  a  rather  peculiar  nature  and  has  to 
be  referred  to  dermatitis.  Intertrigo  is  also  found  in  syphilitic  women, 
.often  accompanying  the  presence  of  mucous  patches  in  the  secondary 
stage.  The  secretion  oozing  from  syphilitic  eruptions,  which  in  that  re- 
gion usually  are  ulcerated,  causes  the  maceration  of  the  epidermis,  and 
intertrigo  is  the  result.  In  these  cases  the  first  thing  to  do  is  to  treat 
the  mucous  patches,  and  with  cleanliness  the  intertrigo  easily  disappears. 

In  the  same  way,  for  the  intertrigo  accompanying  an  acute  gonor- 
rhoea, the  first  indication  is  to  treat  the  gonorrhoea  and  prevent  the  gon- 
orrhoeal  fluid  from  remaining  on  the  skin  of  the  external  genitals.  Al- 
though cleanliness  ma}^  be  maintained,  and  the  improvement  of  the 
acute  gonorrhoea  be  effected,  yet  the  intertrigo  left  to  itself  will  not 
heal,  and  it  requires  some  attention  and  some  local  applications  in 
order  to  bring  about  recovery. 

Treatment. — In  intertrigo  cleanliness  must  be  observed,  so  as  to  re- 
move all  impurities  from  the  irritated  surfaces  of  the  skin.  After  wash- 
ing and  drying,  the  surface  is  covered  with  rice  powder  or  starch  pow- 
der, to  which  may  be  added  a  small  quantity  of  boric  or  salicylic  acid 
(2  to  100). 

When  the  epidermis  is  excoriated,  the  surface  is  sore  and  there  is 
a  great  deal  of  serous  secretion.  Eavogli  finds  of  great  advantage  the 
use  of  bathing  with  some  astringent  solution.  The  solution  of  sub- 
acetate  of  aluminum  and  lead,  known  as  Burow's  solution,  3  per  cent, 
applied  on  lint,  in  order  to  sej)arate  the  skin  surfaces  from  each  other, 
is  very  beneficial.  If  the  patient  can  remain  in  bed,  with  a  few  appli- 
cations of  this  solution  the  intertrigo  will  easily  disappear;  but  if  the 
patient  must  attend  to  her  occupations,  then  bathing  may  take  place 
morning  and  evening,  and  during  the  day  some  salve  may  be  applied, 
such  as  Wilson's  ointment,  or  an  ointment  of — 

3^   Zinci  oxidi,  )  __  ^     , 

Bismuth]  subcarbonatis,  f '' 

Acidi  carbolici gtt.  x; 

Vaselini oj- 

M.     Fiat  unguentum. 

This  can  be  rubbed  on  the  sin-face,  and  particularly  upon  the  labia 
majora,  which  should  be  kept  separated  from  the  thighs  by  means  of 
soft  lint. 

14 


194:  A   TEXT-BOOK  OF   GYNECOLOGY 

In  chronic  intertrigo  with  papillary  hypertrophy  it  is  necessary  to 
use  more  active  remedies.  Two  or  three  applications  of  Wilkinson's 
ointment — 

^   Sulphuris  sublimati,  ) 

Picis  liquidge,  > aa  Svj; 

Saponis  viridis^,  ) 

Terrge  albse oiij; 

Adipis  suis oj. 

M.     Fiat  ung'uentiim. 

have  given  good  results,  for  by  causing  the  desquamation  of  the  old 
epidermis  we  obtain  a  new  soft  epidermis.  The  application  of  a  re- 
sorcin  salve  can  also  be  recommended. 

I^   Eesorcini 3ss.; 

Acidi  salicylici gr.  vj; 

Vaselini  fiavi oj- 

M.     Fiat  ungueutum. 

"When  the  epidermis  has  returned  to  its  normal  condition  and  the 
serous  secretion  has  stopped,  the  only  way  to  finish  the  treatment  and 
prevent  any  relapses  is  to  use  scrupulous  cleanliness,  and  after  washing, 
to  dust  the  genitals  and  genito-crural  region  with  one  of  the  recom- 
mended dusting  powders. 

Erythema. — The  skin  of  the  genitals  of  the  Avoman  is  often  the  seat 
of  erythema,  the  result  of  various  causes.  Obstinate  erythema  affects 
the  female  genitals  in  consequence  of  glycosuria,  and  indeed  it  is  the 
duty  of  the  physician  when  he  finds  cases  of  erythema  localized  in  the 
genitals  to  examine  the  urine.  In  these  cases  the  labia  minora  are  red 
and  slightly  swollen,  the  labia  majora  are  red  and  swollen,  the  colour 
is  rose-red,  of  an  intense  hue,  and  the  epidermis,  distended  from  the 
scanty  exudation  of  serum,  takes  on  a  smooth,  silky,  and  glossy  appear- 
ance. This  erythema  sometimes  spreads  to  the  internal  surface  of  the 
thighs,  but  in  the  usual  cases  it  remains  limited  to  the  genitals.  Ex- 
coriations are  found  on  the  reddened  and  swollen  surface  of  the  skin, 
produced  by  the  act  of  scratching,  because  this  glycosuric  erythema 
is  often  accompanied  by  a  persistent  itching  sensation — pruritus  vulvae. 
Pruritius  is  in  these  cases  very  intense,  and  the  patient  can  not  restrain 
herself  from  scratching  in  order  to  stop  this  disagreeable  itching  sensa- 
tion. This  deprives  the  sufferers  of  their  sleep  at  night,  and  the  con- 
stant scratching  irritates  the  skin  so  much  that  it  produces  a  persistent 
oedema  or  pustules,  and  superficial  ulcerations. 

The  presence  of  sugar  in  the  urine,  moistening  the  mucous  mem- 
brane and  the  skin  of  the  genitals,  is  the  cause  of  the  erythema.  It 
must  not  be  forgotten,  however,  that  the  tissues  of  glycosuric  persons 
offer  a  good  ground  for  the  development  of  the  pus  germs,  and  as  a 
result  they  are  often  troubled  with  persistent  furunculosis. 


DISEASES  OF   THE  SKIN   OP   THE   FEMALE   GENITALS        195 

Treatment. — Although  it  is  difricult  to  cure  this  erythema  on  ac- 
count of  its  persistent  cause^  yet  great  benefit  can  be  obtained  from 
general  and  local  treatment.  For  the  first  object,  it  is  necessary  to  sub- 
ject the  patient  to  the  ordinary  diet  of  diabetics,  by  forbidding  all  amy- 
laceous food  and  thus  diminishing  the  quantity  of  sugar  in  the  urine. 
These  dietetic  rules  must  be  accompanied  by  the  use  of  some  mild 
purgative  mineral  waters,  like  Carlsbad,  Apenta,  Hunyadi  Janos,  Blue 
Lick,  Congress,  etc.,  taken  regularly  every  morning  in  a  dose  of  from 
half  a  glass  to  one  glass,  according  to  the  tolerance  of  the  patient.  For 
local  treatment  the  most  important  rule  to  follow  is  cleanliness.  The 
external  genitalia  and  the  vagina  are  to  be  thoroughly  washed  with 
green  soap  and  water  and  then  irrigated  with  a  2-per-cent  solution  of 
carbolic  acid.  The  patient  is  advised  to  remain  in  bed  and  apply  com- 
presses with  liniment  of  oil  and  limewater,  to  which  may  be  added  from 
2  to  4  per  cent  of  ichthyol.  When  the  patient  gets  up  she  may  make 
an  application  of  Wilson's  salve  or  the  suggested  formula  of  oxide  of 
zinc  and  subcarbonate  of  bismuth.  Lassar  recommends  the  following 
formula: 

I^  Acidi  phenylici 1  to  3  parts; 

Hydrargyri  sulphidi  rubri 1  part; 

Sul23hu.ris  sublimati 25  parts; 

Vaselini  Americani 100        " 

Olei  bergamottas gtt.  xxx. 

M.     Fiat  unguentum. 

This  mixture,  as  it  contains  a  great  quantity  of  sulphur,  without 
causing  irritation  prevents  the  development  of  the  ])ns,  germs  which 
so  often  occur  in  the  skin  of  diabetic  persons. 

(Edema  of  the  vulva  may  depend  upon  any  of  the  conditions  that 
interfere  with  the  free  circulation  of  the  blood  in  the  vulva,  only  a  few 
of  which  are  here  considered.  In  cases  of  oedema  of  the  legs  as  a  con- 
sequence of  heart  disease  or  of  general  anasarca,  the  skin  of  the  geni- 
tals of  the  woman  is  oedematous,  swollen,  of  a  waxy  rose-red  colour, 
the  labia  majora  protrude  in  a  round  shape,  and  are  sometimes  painful 
on  account  of  the  acute  distention  of  the  skin.  The  labia  minora  and 
the  clitoris  are  also  swollen,  presenting  the  same  appearance;  the 
tlughs,  which  are  also  in  an  oedematous  condition,  do  not  permit  the 
woman  to  bring  the  legs  close  together.  There  are,  however,  cases  of 
fjedcma  localized  in  the  genitals  of  the  woman  of  angeioneurotic  ori- 
gin, as  described  by  Quincke,  Jamison,  and  others.  This  oedema  comes 
in  th('  form  of  repeated  attacks,  which  are  often  preceded  by  general 
malaise,  vomiting,  or  diarrhoea.  CEdema  occurs  in  the  form  of  a  local- 
ized swelling  of  a  whitish  waxy  rose-colour,  with  a  certain  brilliancy  of 
the  affected  skin;  it  appears  in  different  regions  of  the  body,  and  the 
genitals  may  be  included.  Eavogli  has  observed  a  woman  subject  to 
attficks  of  this  affection  which  could  with  propriety  be  called  the  giant 
iirti(iirl;i   of   Wilson,     'j'lie  swcllinii:   in   this  case  was  limited  to   the 


196  A  TEXT-BOOK   OF   GYNECOLOGY 

right  labium,  assuming  the  size  of  a  fist,  and  it  was  accompanied  by 
some  j)ain  and  an  itching  sensation.  It  lasted  for  several  hours  and 
then  gradually  disappeared  without  leaving  any  trace.  It  is  easy  to 
understand  that  the  swelling  was  due  to  an  effusion  of  serum  in  the 
meshes  of  the  connective  tissues  of  the  derma  and  of  the  subcutaneous 
tissue,  and  that  the  acute  oedema  was  the  result  of  an  angeioneurotic 
affection,  as  the  patient  had  frequently  had  similar  localized  oedema 
on  half  of  her  face  and  on  her  left  shoulder. 

OKdema  of  the  vulva  as  a  result  of  passive  hyperemia  has  been  ob- 
served by  Eavogli,  in  the  practice  of  Tackier,  in  a  case  of  Kaynaud's 
disease.  One  of  the  labia  majora  was  bluish,  red,  and  swollen,  with  a 
sloughing  j^atch  of  superficial  gangrene,  together  with  the  same  as- 
phyctic symjDtoms  in  several  toes. 

QEdema  accompanied  by  stasis  sometimes  appears  in  one  labium 
on  account  of  a  hard  chancre  concealed  in  the  internal  surface  of 
the  labium  or  in  one  side  of  the  ostium  vaginas.  In  this  case  oedema 
affects  only  one  labium,  which  is  of  a  bluish-red  hue,  showing  the 
location  of  the  obstacle  to  the  circulation.  It  is  scarcely  necessary 
to  say  that  as  soon  as  the  chancre  begins  to  heal  up  the  oedema  dis- 
appears. 

Treatment. — In  cases  of  oedema  of  the  genitals  accompanying  ana- 
sarca, the  treatment  has  to  be  directed  to  relieve  the  general  condition, 
but  the  local  disturbance  must  not  be  neglected.  The  application,  in 
the  form  of  compresses,  of  mild  astringent  solutions,  like  Burow's  solu- 
tion in  a  strength  of  3  per  cent,  or  Goulard's  lotion,  has  been  found 
very  beneficial.  In  the  same  way,  when  stopping  the  application  of 
the  compresses,  the  use  of  dusting  powder,  as  starch  or  rice  powder, 
with  the  addition  of  3  per  cent  of  boric  or  salicylic  acid,  is  found 
of  great  service.  The  nurse  should  apply  soft  linen  pieces  between 
the  folds  of  the  skin,  thus  preventing  the  surfaces  from  rubbing  each 
other  and  causing  intertrigo,  which  often  complicates  oedema  of  the 
vulva. 

Eczema  of  the  Vulva. — Like  any  other  part  of  the  body,  the  skin  of 
the  female  genitals  is  subject  to  eczema  in  acute  and  chronic  forms. 
In  speaking  of  intertrigo  it  was  mentioned  that,  in  consequence  of  the 
neglect  of  care  and  cleanliness,  it  may  be  the  starting  point  of  an 
eczema.  In  the  same  way,  in  cases  of  pruritus  vulvae,  the  irritation 
caused  on  the  skin  by  the  continuous  rubbing  and  scratching  may  be 
the  direct  cause  of  eczema  of  this  region.  The  propagation  of  the 
Staph i/lococcus  pyogenes  alhus  on  the  deeper  layers  of  the  skin  is  to  be 
recognised  as  the  chief  causative  factor. 

Acute  eczema  may  affect  the  vulva,  implicating  the  labia  majora  and 
minora,  clitoris,  and  the  raucous  membrane  of  the  vagina,  spreading 
along  the  periphery  to  the  upper  portion  of  the  thighs.  Along  with  the 
burning  and  itching  sensation,  a  diffused  redness  and  swelling  affects 
the  parts  mentioned,  and  presently  small  vesicles  appear,  which  soon 
break,  causing  a  discharge  of  serum,  which  moistens  the  linen. 


DISEASES  OF  THE  SKIN   OP  THE  FEMALE  GENITALS        197 

Chronic  eczema,  however,  is  the  form  more  often  met  with  when 
locaUzed  upon  the  female  genitals.  It  often  occurs  in  the  form  of  ec- 
zema rubrum,  affecting  the  labia  majora,  labia  minora,  and  the  mucous 
membrane  of  the  vagina.  The  labia  majora  are  red,  swollen,  and  infil- 
trated, and,  in  consequence,  the  rima  vulvEe  is  opened  by  the  distention 
of  the  labia.  On  account  of  the  unbearable  itching  sensation  numerous 
excoriations  are  produced  by  the  action  of  scratching  and  rubbing.  In 
many  cases  the  eczema  spreads  to  the  upper  portion  of  the  thighs  and 
also  to  the  mons  veneris.  On  account  of  the  spreading  of  the  affec- 
tion to  the  vagina,  an  abundant  secretion  oozes  out  of  the  genitals, 
which  increases  the  intensity  of  the  affection.  In  order  to  be  sure  that 
the  secretion  is  not  of  a  venereal  origin,  Ravogli  always  makes  a  micro- 
scopic examination  of  it  so  as  to  exclude  the  possibility  of  the  existence 
of  gonorrhoea. 

Eczema  of  the  vulva  may,  by  continuity,  very  easily  spread  to  the 
perineum  and  to  the  anus.  The  parts  are  red,  thick,  and  excoriated, 
and  serum  oozes  from  the  excoriations.  Sometimes  the  excoriations 
are  covered  with  crusts,  but  where  there  are  opposing  surfaces  these 
become  more  or  less  glued.  At  other  times  no  discharge  takes  place; 
the  skin  is  rough,  dry,  and  slightly  scaly.  It  is  always  accompanied  by 
a  violent  itching  sensation,  which  causes  great  misery.  This  form  of 
eczema  may  be  the  result  of  a  local  irritation,  leucorrhoea  and  gonor- 
rhoea being  the  most  effective  factors;  or  it  may  be  the  result  of  the 
scratching  and  tearing  of  the  skin  incident  to  intertrigo.  It  may  also 
be  of  reflex  origin,  or  it  may  be  referable  to  the  presence  of  uterine  dis- 
orders. 

Treatment. — Eavogli  has  always  obtained  good  results  by  the  appli- 
cation of  ichthyol  in  diiferent  formulge.  First,  care  has  to  be  taken  to 
improve  the  condition  of  the  vagina  by  means  of  irrigations  with  a 
solution  of  biborate  of  sodium,  which  the  patient  will  repeat  twice  a 
day.  Every  other  day  Eavogli  inserts  into  the  vagina  a  tampon  satu- 
rated with  a  mixture  of  25-per-cent  ichthyol  in  vaseline  or  glyc- 
erine, which  the  patient  will  leave  in  the  vagina  for  twelve  hours.  Ex- 
ternally he  directs  the  patient  to  apply  for  a  few  minutes  a  solution  of 
carbolic  acid,  which  relieves  the  itching  sensation  and  sterilizes  the 
afl'ected  skin.    The  formula  which  he  employs  is: 

^  Acidi  carbolici 3j; 

Glycerini .lij; 

Alcoholis oijj 

Aquae  rosse oi"^- 

M.     Fiat  linimentum. 

At  first  llie  |)ntif'nt  complains  of  some  burning  sensation,  but  she  is 
soon  willing  to  repeat  the  application  for  the  relief  which  it  affords  to 
the  itching.  After  this  application  the  patient  is  directed  to  apply 
pieces  of  lint  well  saturated  with  the  following  liniment: 


198  ^  TEXT-BOOK  OF  GYNECOLOGY 

^  Ichth3'0lis oij; 

Olei  amysxlalEe  dulcis,  t  --  ^■ 

.  ''-P.  > aa  oiv: 

Aquae  calcis^  ) 

^ly^^"^^'     I aagj. 

Aquge  rosge,  [ 

M.     Fiat  linimentum. 

The  use  of  salves  is  to  be  ayoicled  in  this  condition,  because  the 
abundant  secretion,  together  with  the  salve,  makes  rather  an  irritant 
mixture. 

After  the  repeated  applications  of  the  ichthyol  liniment  in  the 
manner  described,  the  surface  of  the  skin  begins  to  heal  up,  the  itching 
sensation  greatly  diminishes,  the  swelling  and  the  redness  nearly  sub- 
side, and  at  this  point  there  may  be  applied  a  salve  of  oxide  of  zinc, 
which  will  finish  the  treatment.    The  formula  for  this  salve  is: 

E   Zinci  oxidi,  )  --   ^ 

Bismutlii  subcarbonatis,  \ 

Acidi  carbolici gtt.  x; 

Vaselini  flavi oj- 

M.     Fiat  unguentum. 

When  the  skin  has  returned  to  its  normal  condition  it  will  retain 
some  redness  as  the  result  of  the  past  trouble,  for  the  relief  of  which 
Eavogli  advises  the  patient  to  continue  the  use  of  the  lotion  of  carbolic 
acid  twice  a  day,  and,  after  drying  the  surface,  to  dust  the  skin  with 
an  innocent  powder,  as  starch  or  rice  powder,  to  which  some  oxide  of 
zinc  or  subcarbonate  of  bismuth  may  be  added. 

Folliculitis. — Either  in  consequence  of  an  eczema  or  without  a 
known  cause,  an  inflanunatory  process  may  invade  the  follicles  of  the 
hairs  which  cover  the  female  genitals.  The  affection  is  rather  rare, 
as  Eavogli  has  met  with  this  condition  in  only  two  cases,  where  the 
female  genitals  presented  the  exact  appearance  of  sycosis.  It  is  an  in- 
flammatory affection  in  a  subacute  or  chronic  form,  affecting  the  con- 
nective tissue  of  the  hair  follicles  and  also  of  the  sebaceous  glands 
connected  with  them. 

Bacteriological  studies  have  recently  explained  that,  like  sycosis 
of  the  beard,  folliculitis  may  be  of  double  origin,  either  the  result  of  the 
fungus  of  the  ringworm  or  the  result  of  the  development  of  the  pus 
germs  in  the  follicle  of  the  hair.  In  both  cases  which  Eavogli  had  occa- 
sion to  study,  the  pus  cocci  were  the  cause  of  the  disease.  In  both  cases 
the  affection  started  from  a  superficial  eczema  and  had  developed  until 
the  surface  gradually  became  covered  with  pustules,  conical  in  shape, 
each  one  having  a  hair  in  the  middle. 

It  is  easy  to  understand  how  the  pus  germs  find  their  way  into  the 
follicles  of  the  hair.  The  opening  from  which  the  hair  passes  through 
the  epidermis  is  lined  with  epidermic  cells,  forming  a  kind  of  funnel 
around  the  shaft  of  the  hair.    According  to  Bockhart,  the  pus  germs 


DISEASES  OP  THE  SKIN   OF  THE  FEMALE   GENITALS        199 

capable  of  producing  this  affection  are  the  Staphylococcus  alhus, 
aureus,  and  citreus,  the  same  that  can  produce  impetigo  and  furun- 
culosis.  On  account  of  an  inflammatory  process,  especially  eczema,  the 
germs  find  the  follicular  openings  more  easy  of  access  than  in  the  nor- 
mal condition,  and  insinuate  themselves  into  the  follicles,  thus  causing 
inflammation  of  the  tissues  forming  the  follicle  of  the  hair,  and  of  the 
surrounding  tissues.  It  will  be  seen  that  this  is  nothing  more  than  a 
spreading  of  the  process  by  continuity,  when  it  is  remembered  that 
eczema  is  only  the  result  of  the  production  and  development  of  the 
Staphylococcus  pyogenes  alius  in  the  layers  of  the  epidermis. 

The  hair  follicle,  inflamed  and  swollen,  is  converted  into  a  small 
abscess,  as  proved  by  AVertheim.  A  transudation  of  serum  and  white 
corpuscles  of  the  blood  takes  place  in  the  hair  follicle,  producing  a 
hydropic  condition  of  the  membranes  covering  the  root  of  the  hair. 
The  root  is  softened  and  swollen  by  sero-purulent  infiltration,  and  in 
consequence  the  hair  is  easily  removed,  having  no  adherence.  The 
papilla  is  usually  spared  from  destruction,  and  this  is  the  reason  why 
in  all  cases  of  sycosis  the  hair  is  easily  reproduced. 

Symptoms. — As  in  ordinary  cases  of  sycosis,  the  folliculitis  of  the 
female  genitals  is  revealed  by  the  presence  of  pustules  or  papulo-pus- 
tules,  each  one  being  perforated  by  a  hair.  The  pustules  are  conical 
in  shape  and  contain  a  drop  of  pus  at  the  point  surrounding  the  shaft 
of  the  hair.  The  skin  of  the  labia  majora  and  of  the  mons  veneris, 
when  affected  with  folliculitis,  is  usually  red  and  inflamed.  This  is 
accompanied  by  a  burning  and  itching  sensation.  This  aff'ection  is 
often  associated  with  boils  in  the  same  region  or  in  the  neighbouring 
parts  of  the  thighs  or  abdomen,  caused  by  the  inoculation  with  the 
staphylococci  effected  by  the  finger  nails  in  the  act  of  scratching.  This 
affection  of  the  follicles  of  the  hair  of  the  woman's  genitals,  although 
chronic  and  obstinate,  is  not  so  difficult  to  treat  as  sycosis  of  the  beard. 
It  may  be  said  that  without  the  necessity  of  removing  the  hair,  either 
by  shaving  or  by  epilation,  this  disease  can  easily  be  treated,  yielding 
readily  in  a  few  weeks  to  the  action  of  remedies. 

Treatment. — Of  course  the  general  system  should  not  be  neglected, 
although  the  disease  is  a  local  one.  The  condition  of  resistance  of  the 
organism  to  the  development  of  the  pus  germs  is  very  important,  and 
when  we  begin  the  treatment  it  is  necessary  to  establish  a  plan  of  gen- 
eral medication.  If  the  patient  is  in  an  anaemic  condition,  prescribe 
ferruginous  and  tonic  preparations;  if  she  is  suffering  from  a  scrofulous 
condition,  the  use  of  cod-liver  oil  will  be  of  great  advantage.  In  case 
the  woman  is  inclined  to  gout,  or  if  she  perspires  a  great  deal,  we  must 
prescribe  anti-gout  remedies,  such  as  lithia,  salol,  salicylates,  etc. 

The  local  treatment  consists  in  enforcing  rules  of  cleanliness. 
Ravogli  uses  with  good  results  an  application  of  compresses  well  satu- 
rated in  an  astringent  and  antiseptic  solution,  and  frequently  repeated; 
also  compresses  saturated  with  a  mild  solution  of  bichloride  of  mer- 
cury (1  to  1,000)  for  half  an  hour  twice  a  day,  followed  by  the  applica- 


200  A  TEXT-BOOK  OF  GYNECOLOGY 

tion  of  a  salve,  such  as  Wilson's  ointment.    In  more  stubborn  cases  the 
following  formula  can  be  used  with  good  results: 

I^   Acidi  carbolic! gr.  v; 

Bismuthi  subnitratis oss.; 

Unguenti  hydrargyri  ammoniati 5ij ; 

Unguenti  aqua3  vosse oiv. 

M.     Fiat  unguentum. 

The  application  of  ichythol  is  highly  recommended.  This  is  used 
in  liniment  form  applied  on  lint,  or  in  the  form  of  salve,  10  per  cent, 
in  association  with  zinc  ointment  and  2  per  cent  beta-naphthol. 

Salves  containing  sulphur,  from  4  to  6  per  cent,  are  also  found 
very  useful.    It  can  be  applied  in  the  form  of  Lassar's  paste: 

^   Sulphuris   sublimati,  ] 

Zinci  oxidi,  I aa  oj; 

Amyli  oryz^,  ) 

Acidi  salicylici gr.  x; 

Vaselini   3J. 

M. 

With  this  treatment  and  without  any  necessity  of  epilating,  as  in 
the  case  of  sycosis  of  the  beard,  we  can  obtain  good  results  in  a  short 
time. 

Herpes  Progenitalis. — An  eruption  of  vesicles  disposed  in  groups,  in 
an  acute  form,  is  often  found  on  the  genitals  of  women.  It  corresponds 
to  the  herpes  preputialis  which,  with  the  same  frequency,  occurs  in 
the  male  sex.  This  eruption  appears  on  the  internal  surface  of  the 
labia  majora,  on  the  labia  minora,  on  the  vestibule  and  prepuce  of  the 
clitoris,  at  the  orifice  of  the  urethra,  occasionally  on  the  external  sur- 
face of  the  labia  majora,  and  at  times  it  spreads  to  the  mons  veneris. 
Eavogli  has  twice  seen  groups  of  vesicles  on  the  cervix  uteri,  corre- 
sponding with  the  observations  of  Bergh  (ttber  Herpes  Menstrualis, 
Monatshefte  fiir  PrahtiscJie  Definatologie,  1890),  who  has  seen  similar 
eruptions,  sometimes  accompanied  by  herpes  of  the  vulva. 

Before  the  outbreak  of  the  vesicles  there  are  in  most  cases  slight 
burning  and  itching  sensations.  Only  rarely  is  the  itching  very  pro- 
nounced, and  it  accompanies  the  course  of  the  affection. 

The  eruption  consists  of  a  single  vesicle,  or  of  a  group  of  vesicles 
closely  arranged,  or  of  vesicles  scattered  on  the  surface  following  the 
ramification  of  a  nerve.  It  begins  as  a  red  patch,  which  in  a  few  hours 
shows  vesicles.  These  are  usually  small,  from  the  size  of  a  pinhead  to 
that  of  a  hempseed,  round,  transparent,  containing  clear  serum.  When 
affecting  the  mucous  membrane,  on  account  of  the  succulence  and  the 
thinness  of  the  epithelium  they  soon  break,  while  on  the  skin  they  re- 
main longer.  Their  contents  become  turbid  and  soon  form  brownish- 
yellow  crusts. 


DISEASES  OF   THE   SKIN  OF  THE   FEMALE   GENITALS        201 

When  the  herpes  is  seated  on  the  labia  minora  it  may  cause  oedema 
of  these  parts,  on  account  of  the  tenderness  and  laxity  of  their  tissues. 
The  vesicles  when  broken  leave  a  superficial  exulceration  corresponding 
to  the  size  of  the  vesicle.  The  bottom  is  of  a  rose-red  colour,  some- 
tim'es  covered  with  yellow  detritus,  with  the  edges  cleanly  cut,  but  not 
deep,  and  never  as  in  chancroid.  They  are  usually  arranged  in  a  group, 
and  when  broken  the  remaining  exulcerations  coalesce  into  one  patch 
with  festooned  edges,  reminding  one  of  the  round  pre-existing  vesicles. 
The  vesicles  are  seated  on  an  inflammatory  base  and  heal  up  usually  in 
a  few  days;  in  some  cases  they  are  persistent;  in  rare  cases  they  become 
ulcerated,  and  it  is  difficult  to  distinguish  them  from  a  chancroid.  Un- 
cleanliness  and  the  presence  of  gonorrhoeal  fluid  sometimes  irritate  the 
resulting  exulcerations  of  the  vesicles  and  make  them  persistent. 
Herpes  is  inclined  to  relapse  at  different  intervals,  but  relapses  in  women 
are  not  so  frequent  as  in  men. 

The  causes  of  herpes  progenitalis  are  difficult  to  determine.  Usu- 
ally this  affection  is  the  consequence  of  an  irritation  or  congestion  of 
the  sexual  organs.  In  neurotic  women  it  is  found  in  connection  with 
menstruation,  so  that  nearly  every  month  it  is  reproduced.  In  puellce 
publico;  cases  of  herpes  progenitalis  are  often  met  with  on  account  of 
frequent  and  forced  coitus,  and  also  on  account  of  disproportion  of  the 
parts.  Herpes  often  appears  in  cases  of  gonorrhoeal  inflammation  of 
the  female  genitals,  and  is  often  the  result  of  endometritis,  salpingitis, 
and  oophoritis.  It  may  be  considered  as  an  abortive  zoster,  proceeding 
from  irritation  and  the  nervous  ramifications  of  the  pudenda,  and  some- 
times it  shows  this  clearly  by  the  disposition  of  the  eruptive  patches. 

Although  herpes  progenitalis  has  been  often  suspected  to  be  the 
result  of  the  presence  of  cocci,  yet  so  far  there  is  nothing  positive  in 
this  regard.  Eohrer  {Monatsliefte  fiir  Prahtische  Dermatologie,  1888) 
found  very  few  diplococci  in  the  serum  of  the  vesicles,  and  Pfeiffer 
(ibid.,  1887)  in  a  case  of  menstrual  herpes  could  not  find  any  micro- 
organisms. 

The  diagfiosis  of  herpes  progenitalis  is  easily  made  if  the  vesicles  are 
still  present.  When,  however,  the  vesicles  are  broken  and  an  ulceration 
remains,  there  may  be  some  difficulty  in  distinguishing  herpes  from 
venereal  or  syphilitic  ulcerations.  The  superficial  character  of  the 
lesion,  the  scanty  serous  secretion,  the  peculiar  round  disposition  of 
the  edges,  the  smoothness  of  the  surface,  are  characteristics  enough  to 
show  us  that  we  have  to  do  with  a  case  of  herpes.  Sometimes,  however, 
a  hard  chancre  in  its  erosive  stage  has  been  mistaken  for  herpes.  (See 
Syphilis  of  the  Vulva).  In  women,  in  whom,  especially,  the  hardness 
of  the  lesion  is  often  not  clear,  we  lack  one  of  the  most  important  char- 
acteristics for  diagnosis.  Tlie  surface  of  a  chancrous  erosion  is  usually 
deeper  in  colour,  round  in  shape,  with  a  smooth  surface,  and  is  found 
in  places  where  the  lierpes  floes  not  usually  appear,  as  in  the  fourchette 
and  in  the  ostium  vagina). 

With  reference  to  the  possible  confusion  of  herpes  with  chancroid. 


202  A  TEXT-BOOK  OF   GYNECOLOGY 

it  is  difficult  for  it  to  occur  when  we  keep  in  mind  the  appearance  of 
the  chancroid  lesion,  which  is  the  most  reliable  diagnostic  by  itself. 
Indeed,  the  jaunched-out,  round,  irregular,  or  ragged,  often  undermined 
ulcer,  which  rapidly  spreads,  accompanied  with  abundant  secretion,  and 
exhibiting  an  unhealthy,  diphtheroid,  worm-eaten  surface,  can  not 
admit  of  confusion.  At  any  rate,  especially  in  the  beginning,  when 
no  other  diagnostic  characteristics  are  present,  in  case  of  doubt  it  is 
better  to  suspend  diagnosis,  being  sure  that,  on  the  following  day,  the 
doubt  will  be  dispelled. 

Treatment. — As  already  stated,  the  use  of  douches  with  warm  water, 
having  in  solution  some  borate  of  sodium  or  any  other  mild  antiseptic, 
is  advised.  The  general  health  of  the  patient  must  receive  its  proper 
care,  and  the  use  of  mild  saline  purgatives  is  advisable  when  an- 
noyed with  constipation,  alkaline  mineral  waters  when  troubled  with 
catarrhal  conditions  of  the  digestive  organs,  iron  tonics  and  recon- 
structives  when  symptoms  of  anemia  and  general  denutrition  are  pres- 
ent. Locally,  the  application  of  a  wash  containing  lead  and  opium  is 
very  useful,  especially  when  the  herpetic  eru^jtion  is  accompanied  with 
pain  and  irritation.  Touching  the  ulcerated  surface  with  a  solution 
of  nitrate  of  silver,  from  6  to  8  f)er  cent,  has  given  very  satisfac- 
tory results.  The  surface  is  then  covered  with  an  innocent  salve,  as 
Wilson's  ointment,  or  with  vaseline  containing  some  carbolic  or  sali- 
cylic acid.  The  application  of  powders  is  also  used  with  some  benefit. 
Iodoform  is  objectionable  because  of  its  odour;  but  aristol  and  euro- 
phen  are  applied  with  advantage  on  the  exulcerated  surface.  The  pow- 
ders have  the  disadvantage  that  they  form  crusts  with  the  secretion, 
which  soil  the  exulcerated  surface.  Ravogli  prefers  the  use  of  powders 
when  the  surface  is  healing,  at  which  time  the  parts  may  be  dusted 
with  oxide  of  zinc,  subnitrate  of  bismuth,  rice  powder,  or  any  other 
substance  capable  of  keeping  the  surfaces  dry  and  separated. 

The  application  of  camphorated  alcohol  has  been  used  as  an  abor- 
tive measure,  and  in  the  same  way  Depas,  of  Lille,  advocates  the  applica- 
tipn  of  compresses  of  absolute  alcohol,  to  which  2  per  cent  of  resorcin 
and  1  per  cent  each  of  menthol  and  carbolic  acid  are  added. 

Pruritus  Vulvse. — In  this  affection  there  is  no  apparent  eruption  on 
the  genitals;  it  is  characterized  only  by  an  intense  itching  sensation 
of  the  vulva  and  of  the  vagina  without  apparent  external  causes.  In 
cases  of  the  presence  of  eczema,  of  lichen,  prurigo,  or  of  insects,  the 
itching  is  due  alike  to  the  alteration  of  the  skin  and  to  the  irritation 
of  the  insects;  but  in  cases  of  pruritus  vulvae  the  itching  is  the 
only  symptom — one  so  persistent  and  so  intense  that  it  compels  the 
woman  to  scratch  and  to  rub  the  genitals,  producing  excoriations.  If 
this  condition  lasts  some  time,  then  eczema,  inflammation,  swelling, 
and  oedema  of  the  skin  of  the  genitals  are  often  found,  caused  by  the 
scratching  and  tearing  of  the  skin.  The  continuous  itching  and  the 
desire  to  scratch  and  rub  the  genitals  makes  the  woman  inclined  to 
masturbation  or  to  coitus,  rendering  her  hysterical  and  nymphomani- 


DISEASES  OP  THE  SKIN  OP  THE  PBMALE  GENITALS        203 

acal.  The  irritation  from  scratching  and  the  inflammatory  process  of 
the  external  genitals  spread  to  the  mucous  membrane  of  the  vagina 
and  cause  a  catarrhal  discharge  from  this  organ,  which  increases  the 
itching  sensation. 

Pruritus  vulvae  is  more  often  met  with  at  the  time  of  the  menopause 
in  women  who  are  of  nervous  disposition  or  suffering  from  the  recog- 
nised neuroses.  At  other  times  it  is  a  premonitory  symptom  of  a  great 
many  lesions  of  these  organs,  as  fibroma,  and  sometimes  of  carcinoma. 

The  pathology  of  pruritus  vulva3  has  been  carefully  studied  by  J.  C. 
Webster.     {Transactions  of  the  Edinburgh  Obstetrical  Society,  1890-91.) 

As  regards  the  naTced-eye  appearances,  there  may  be  more  or  less 
hypertrophy,  or  none  at  all.  As  regards  the  hypertrophy  in  such  cases, 
it  is  impossible  to  say  whether  it  is  to  be  associated  with  the  primary 
pruritus  or  to  be  regarded  as  resulting  from  continued  rubbing  and 
scratching.  It  is  not  a  constant  factor.  There  are  also  many  cases  of 
simple  hypertrophy  without  any  accompanying  itchiness.  The  micro- 
scopical changes  found  in  the  tissues  removed  in  Webster's  cases  were 
of  great  interest,  and  were  probably  the  cause  of  the  disease.  These 
changes  were  of  the  nature  of  a  slowly  progressing  fibrosis,  affecting 
chiefly  the  nerves  and  nerve  endings  of  the  clitoris  and  labia  minora. 
Many  of  the  nerves,  if  traced  from  deeper  parts  toward  their  termi- 
nations, were  seen  to  acquire  a  dense  fibrous  character,  some  appear- 
ing as  well-marked  fibrous  cords,  the  nerve  fibres  being  compressed  or 
destroyed.  In  some  cases  they  could  be  followed  to  their  special  end 
corpuscles,  which  also  showed  the  same  changes.  The  changes  were 
most  marked  in  the  clitoris. 

The  Pacinian  corpuscles  did  not  appear  to  be  affected,  save  in  one 
instance  where  there  were  an  abnormal  number  of  cells  in  the  central 
core.  Some  globular  end  bulbs  showed  an  increased  number  of  cells; 
others  appeared  as  dense  fibrous  knobs.  Some  of  the  genital  corpuscles 
showed  the  change  in  a  marked  degree,  the  windings  of  the  terminal 
nerve  fibres  being  often  almost  obliterated.  The  changes  found  in  the 
connective-tissue  framework  of  the  clitoris  and  nymphae  were  different, 
being  of  a  subacute  inflammatory  nature,  and  evidently  more  recent  in 
origin  than  those  found  in  the  nervous  structures.  They  were  found 
most  marked  in  the  corium  under  the  papillae,  and  affected  especially 
the  prepuce  and  nymphae,  being  found  in  the  clitoris  only  in  the  glans 
under  the  epithelium,  and  much  less  marked  than  in  the  labia  minora. 
In  the  corium  of  the  latter  were  seen  many  minute  vessels  with  abun- 
dant exudation  of  leucocytes  into  the  perivascular  lymphatics,  while  in 
many  parts  the  subepithelial  tissue  was  a  mass  of  leucocytes  and  prolif- 
erating connective-tissue  corpuscles.  These  changes  were  most  marked 
in  the  hypertrophic  nymphae.  They  were  distinct  from  the  chronic 
fibrosis  aft'ecting  the  nervous  structures,  and  were,  no  doubt,  due  to 
the  long-continued  irritation  of  the  scratching.  They  affected  chiefly 
the  superficial  parts — viz.,  the  prepuce  and  nymphae — the  nerve  fibrosis 
being  most  marked  in  the  clitoris,  in  which  there  were  only  a  very  few 


204  A  TEXT-BOOK  OF  GYNECOLOGY 

acute  or  subacute  changes  under  the  epithelium  covering  the  surface 
of  the  glans. 

The  causation  of  pruritus  vulvse  has  always  been  shrouded  in  more 
or  less  mystery.  While  it  is  true  that  it  is  only  a  symptom,  its  pres- 
ence does  not  imply  the  existence  as  a  cause  of  any  of  the  recognised 
pruriginous  diseases  of  the  skin  of  the  vulva.  It  is  true  that  in  these 
affections  itching  is  a  conspicuous  and  aggravating  symptom,  but  it 
is  one  the  existence  of  which  is  explained  by  manifest  pathologic 
changes.  In  pruritus  vulvae  there  are  no  such  obvious  changes;  or,  if 
there  are,  they  are  as  liable  to  be  consequences  as  causes.  Bronson 
considers  a  general  neurotic  condition,  either  congenital  or  acquired, 
as  a  predisposing  cause,  and  recognises  a  state  of  impaired  conduction 
in  the  nerve  of  tactile  sense  as  another  causative  factor.  Though  this 
usually  occurs  as  a  concomitant  of  hypersesthesia  of  the  skin,  it  is  pos- 
sible that  it  may  exist  independently  of  the  latter,  particularly  in  the 
atrophic  changes  of  old  age,  while  among  the  exciting  causes  he  speaks 
of  irritations  transmitted  from  nerve  centres,  direct  or  local  irritations, 
from  irritants  applied  to  the  skin,  or  from  intracutaneous  sources,  such 
as  the  lesions  of  trophic  cutaneous  diseases  and  their  products;  toxic 
or  noxious  materials  deposited  from  the  blood;  effects  of  local  nutritive 
disturbance  or  deranged  metabolism  in  the  cutaneous  sensory  nerves; 
and,  finally,  spastic  contraction  of  the  arrectores  pilorum  muscles. 
While  this  summarization  of  tlie  etiology  of  the  disease  deals  largely 
with  more  or  less  speculative  pathology,  it  is  still  suggestive  of  what 
closer  observation  may  prove  to  be  the  real  causation  of  the  disease. 
Ravogli,  in  common  with  other  observers,  recognises  diabetes,  or  rather 
diabetic  urine,  as  an  exciting  cause.  Feinberg  (Centralblatt  fur  Gynd- 
Jcologie)  described  two  cases  of  idiopathic  pruritus  vulvae,  occurring 
during  the  course  of  pregnancy,  in  which  the  aggravating  symptoms 
subsided  after  parturition. 

Treatment  consists  in  cold  applications,  alcoholic  or  ethereal,  in  the 
form  of  compresses  applied  on  the  genitals.  Cold  is  more  apt  to  relieve 
the  itching  than  warm  applications.  In  these  solutions  some  carbolic 
or  salicylic  acid  may  be  dissolved  in  the  ratio  of  2  per  cent,  and  in 
these  cases  affords  some  benefit.  Sitz  baths  with  warm  water,  to  which 
some  bran  has  been  added  or  some  sodium  bicarbonate,  are  to  be  rec- 
ommended. In  the  same  way  the  application  of  vaginal  douches  with 
mild  solution  of  borate  of  sodium,  alum,  etc.,  are  beneficial;  these 
douches  should  be  followed  by  the  application  of  tampons  dipped  in 
some  ointment  containing  opium;  but  the  application  which  in  Ravog- 
li's  hands  has  been  most  frequently  successful  is  a  tampon  dipped  in 
ichthyol  (25  to  50  per  cent)  and  glycerine.  In  very  severe  cases  resort 
to  suppositories  of  cacao  butter  with  one  fifth  of  a  grain  of  morphine  or 
cocaine  has  been  recommended. 

Kholmogoroff  reports  success  from  the  use  of  galvanism  with  the 
positive  electrode,  insulated  to  its  distal  tip,  introduced  4  or  5  centi- 
metres within  the  vagina,  while  the  negative,  covered  with  chamois 


DISEASES  OP   THE   SKIN   OP  THE   FEMALE   GENITALS        205 

and  moistened  with  a  salt  solution,  was  applied  over  the  affected  area. 
It  should  be  remembered  in  this  connection  that  chamois  repeatedly 
applied  to  the  skin  may  become  infected  and  itself  become  the  carrier 
of  infection.  Heidenhain  applies  compresses  wet  with  a  hot  solution 
of  a  tablespoonful  of  tannin  in  a  quart  of  water,  the  vagina  having 
been  previously  douched  with  an  antiseptic  solution.  This  treatment 
is  repeated  every  night.  Mtrate  of  silver,  sulphate  of  zinc  in  solution, 
and  thymol  in  a  10-per-cent  ointment,  are  recommended  as  valuable 
remedies.  It  is  probable  that  for  the  relief  of  the  purely  functional 
pruritus  careful  attention  to  a  hygienic  regime  comjDrises  the  best  rem- 
edy. This  should  consist  in  frequent  local  ablution  not  attended  with 
undue  friction,  in  following  a  wholesome  and  laxative  diet,  and  in 
relieving  the  generally  accompanying  constipation. 

Surgical  Treatment. — When,  however,  pruritus  vulvae  ceases  to  be  a 
purely  functional  disturbance  and  depends  for  its  continuance  upon 
the  development  of  fibrosis  in  the  terminal  nerve  filaments,  as  described 
by  Webster,  the  change  must  be  looked  upon  as  permanent  and  topical, 
and  constitutional  remedies  must  be  recognised  as  quite  inefficient. 
Eelief  under  these  circumstances  can  be  given  the  agonized  patient 
only  by  freely  excising  the  affected  area.  In  determining  the  extent  of 
this  operation  it  is  essential  first  to  ascertain  the  limits  of  the  pruri- 
ginous  areas.  These,  when  ascertained  and  delimited,  should  be  freely 
excised.  The  operation  will  generally  involve  the  removal  of  the 
clitoris  and  its  prepuce,  the  labia  minora,  and  frequently  the  integu- 
ment from  the  inner  aspect  of  the  labia  majora.  In  the  performance 
of  this  operation  the  procedure  designated  in  the  chapter  on  clitoridec- 
tomy  may  be  followed,  the  only  change  consisting  in  the  extension  of 
the  area  of  denudation. 

Parasitic  Affections  of  the  Skin  of  the  Female  Genitals. — The  skin 
of  this  region  is  sometimes  affected  with  the  vegetable  parasite  Tricho- 
phyton tonsurans  in  the  form  of  eczema  marginatum.  On  account  of  the 
condition  of  the  skin,  which  is  often  macerated  by  the  perspiration,  the 
affection  has  so  peculiar  an  appearance  that  for  a  long  time  it  has  been 
■discussed  whether  it  was  the  result  of  the  same  parasite,  and  for  this 
reason  Hebra  called  it  eczema  marginatum.  At  present  it  is  accepted 
that  this  affection  is  nothing  else  than  an  ordinary  ringworm,  modified 
in  its  appearance  by  the  locality.  The  moist  condition  of  the  epi- 
dermis allows  the  parasite  to  grow  with  more  vigour,  and  the  increased 
inflammation  gives  the  different  appearance  to  the  affection.  It  is  an 
affection  found,  not  only  on  the  genitals,  but  wherever  two  surfaces 
of  the  skin  are  close  to  each  other.  In  this  way  we  find  eczema  mar- 
ginatum of  the  axilla,  of  the  breast,  and  of  the  cruro-genital  fold. 

It  is  usually  seen  when  fully  developed.  It  appears  as  a  reddish, 
moist,  pigmented  area  circumscribed  by  a  red,  somewhat  raised  border, 
forming  a  circle  or  an  arc  of  a  circle.  The  border  is  formed  by  small 
papules  or  vesicles  covered  with  brownish-yellow  crusts.  The  surface 
is  often  excoriated  as  a  consequence  of  scratching  on  account  of  the 


206  A  TEXT-BOOK  OF  GYNECOLOGY 

itching  sensation  accompanying  tliis  affection.  The  rings  do  not  re- 
main limited  to  the  genital  sphere;  sometimes  when  the  disease  is  left 
without  treatment  they  grow  to  reach  the  anal  region,  and  spread  on 
the  pubis. 

It  is  rather  difficult  to  demonstrate  the  presence  of  the  Trichophyton 
tonsurans  in  the  scales  or  in  the  crust,  but  with  some  patience  and 
repeated  experiments  the  fungus  is  found,  in  appearance  like  that  of 
the  ordinary  ringworm. 

It  is  easily  cured;  sulphur  is  the  best  remedy.  Ravogli  directs  the 
patient  to  wash  the  parts  with  green  soap,  and  after  washing  and  dry- 
ing, the  affected  skin  is  covered  with  a  thick  layer  of  Wilkinson's  oint- 
ment, of  which  we  have  already  given  the  formula  (page  194).  Bulkley 
recommends  the  use  of  sulphurous  acid,  applied  in  the  form  of  com- 
presses on  the  surface.  Many  other  remedies  are  used  in  trichophyton, 
such  as  chrysarobin  or  beta-naphthol,  in  the  form  of  salves,  which  can 
also  be  applied  with  good  results. 

The  affection  is  easily  manageable,  and  after  six  or  eight  applica- 
tions of  Wilkinson's  ointment,  continiied  until  the  epidermis  exfoliates, 
we  are  sure  of  the  success  of  our  treatment. 

Pediculi  Pubis. — A  kind  of  pediculus  called  Phtheirius  inguinalis 
may  be  found  infesting  the  hairy  parts  of  the  woman's  pubic  region. 
Although  the  hairs  of  the  pubes  are  the  ordinary  habitat  of  this  insect, 
yet  it  may  also  find  its  way  to  the  hair  of  the  axillse,  and  in  the  man  to 
the  beard.  This  insect  has  a  peculiar  shape,  resembling  the  form  of  a 
crab,  and  for  this  reason  it  has  been  called  crab  louse,  and  vulgarly 
crabs.  It  hangs  to  the  shaft  of  the  hair,  inserting  its  proboscis  into 
the  follicle  so  as  to  obtain  its  nourishment  from  the  sebaceous  glands. 
To  the  naked  eye  it  looks  like  a  3rellowish  scale  or  a  little  crust.  It 
causes  a  great  deal  of  itching  sensation,  but  this  is  seldom  so  severe  as 
to  cause  deep  excoriation,  as  in  the  case  of  the  body  louse.  It  always 
comes  by  contagion;  sexual  intercourse  is  the  most  common  way  of 
transmission  of  this  insect,  but  it  can  be  taken  also  from  clothing,  bed- 
ding, and  from  contact  with  the  seat  board  of  a  public  water-closet. 

This  insect  is  very  inactive;  it  hangs  fast  to  the  hair  and  to  the 
skin,  so  that  it  is  difficult  to  detach  it.  With  its  powerful  claws  it  holds 
firmly  to  the  hair,  so  that  in  attempting  to  remove  it,  it  slides  for  some 
distance  before  loosening  its  hold.  The  eggs  of  this  louse  are  small 
and  adhere  to  the  hair. 

A  close  inspection  of  the  part  affected  will  reveal  the  presence  of 
the  insect  and  of  the  nits. 

Treatment. — The  old  application  of  mercurial  ointment  is  still  to 
be  recommended;  one  or  two  applications  are  sufficient  to  destroy  the 
insect  and  the  nits.  This  application,  however,  is  somewhat  dirty  and 
may  produce  irritation  and  dermatitis.  The  ointment  of  white  precipi- 
tate is  also  recommended.  In  his  clinic  Eavogli  finds  that  coal  oil 
gives  good  results;  two  applications  are  enough  to  kill  the  insects  and 
nits.    Oleate  of  mercury  has  also  a  good  effect.    After  any  one  of  these 


DISEASES  OF  THE   SKIN  OF  THE   FEMALE  GENITALS        207 

applications  the  patient  takes  a  bath  and  changes  the  clothes  in  order 
to  prevent  a  new  transmission. 

Atrophy  of  the  External  Female  Genitals   (Kraurosis  Vulvae). — 

Under  the  name  of  kraurosis  vulvce  there  has  been  recently  described  an 
atrophy  of  the  vulva.  The  name  was  given  to  the  affection  by  Breisky, 
using  the  Greek  name  Kpavpo's,  parched,  hence  withered.  The  atrophy  is 
strictly  limited  to  the  skin  and  to  the  subcutaneous  tissue,  involving  the 
labia  majora,  the  fourchette,  and  sometimes  the  perineum.  Charles 
A.  L.  Eeed  {New  Yorh  Medical  Journal,  September  39,  1894)  stated 
that  he  had  never  been  able  to  observe  either  clinically  or  micro- 
scopically the  extension  of  this  disease  to  the  mucous  membrane  of  the 
ostium  vaginae,  and  he  believes  that  this  affection  is  essentially  re- 
stricted to  the  vulvar  integument.  For  this  reason  the  disease  has  also 
been  given  the  more  appropriate  name  of  progressive  cutaneous  atrophy 
of  the  vulva. 

The  first  description  of  this  disease  is  due  to  Eobert  F.  Weir,  of 
JSTew  York,  who  in  1875  described  this  affection  as  an  ichthyosis  vulvae. 
(Ichthyosis  of  the  Tongue  and  Vulva,  Neio  Yorh  Medical  Journal, 
March,  1875.)  Although  he  believed  that  he  was  describing  a  case  of 
ichthyosis,  yet  the  sym23toms  have  such  an  analogy  with  those  of  this 
affection  that  there  is  no  doubt  that  he  described  a  case  of  kraurosis. 
The  knowledge  of  this  disease  is  really  due  to  Breisky,  of  Prague 
{Archiv  filr  JleiTkunde,  Prague,  1885).  In  1885  he  reported  twelve  cases 
with  a  careful  study  of  the  symptomatology  and  of  the  pathologic 
alterations.  Possibly  such  cases  had  come  to  the  attention  of  the 
gynecologist  before  that  time,  but  the  condition  had  not  been  pointed 
out  as  a  pathologic  entity.  Since  the  publication  of  Breisky  the  sub- 
ject has  been  brought  to  the  attention  of  the  Obstetrical  and  Gyneco- 
logical Society  of  Berlin,  where,  after  a  full  consideration,  the  disease  in 
question  was  recognised  as  a  morbid  entity. 

The  first  changes  perceptible  to  the  naked  eye  are  small  reddish 
areas  around  the  ostium  vaginae;  they  are  not  elevated;  on  the  contrary, 
they  are  somewhat  depressed.  They  are  painful  to  the  touch,  and  sex- 
ual intercourse  is  painful  and  futile.  The  vaginal  orifice  is  very  nar- 
row, and  there  is  a  diminished  elasticity  of  the  tissues.  The  skin  and 
the  mucous  membrane  have  at  this  point  lost  a  great  deal  of  their 
pigment  and  have  become  thin  and  translucent,  tense  and  glossy,  so  as 
to  have  lost  all  the  normal  folds  of  the  vulva.  The  ostium  vaginse  is 
very  narrow.  The  shrinkage  is  one  of  the  leading  features  of  this 
disease,  but  it  is  manifested,  not  over  the  whole  region,  but  in  different 
areas.  Prom  tbese  centres  the  process  gradually  extends  until  the 
vulva  has  been  entirely  involved.  The  labia  minora  are  fused  together 
with  the  labia  majora,  and  scarcely  a  trace  of  them  is  to  be  seen  (Fig- 
72).  in  some  cases  the  mons  veneris  is  also  found  in  an  atrophic  con- 
dition, associated  with  complete  alopecia. 

According  to  the  observations  of  Breisky,  in  none  of  his  cases  had 
there  existed  symptoms  of  itillatnmation  or  of  exanthematous  affection 


208 


A   TEXT-BOOK  OP  GYNECOLOGY 


in  the  external  genitals.  In  some  of  his  patients  an  unbearable  itching 
sensation  was  present.  Some  of  the  women  were  pregnant  and  the 
itching  sensation  spontaneously  disappeared  at  the  end  of  the  gesta- 
tion.    In   one   of   the   gynecological   cases   the   woman   suffered   with 

an  itching  sensation, 
which  lasted  only  a 
few  weeks.  In  two 
private  cases  he 
found  one  patient 
who  had  been  afflict- 
ed with  pruritus  for 
several  years,  the  af- 
fection being  most 
annoying  at  night; 
she  also  had  leucor- 
rhcea  and  menor- 
rhagia.  In  another 
case  the  pruritus  had 
been  present  for 
nearly  three  years, 
with  relapses  at  the 
time  of  the  menstru- 
ation lasting  from 
two  to  three  days. 

Breisky  drew  his 
conclusions  from  the 
consideration  of  all 
his  cases  as  follows: 
That  chronic  vaginal 
catarrh  was  present 
in  4  cases;  that  in  2 
cases  scars  were  pres- 
ent from  progressed 
scrofulous  abscesses 
of  the  cervical 
glands;  not  one  had 
suffered  with  syphi- 
lis; 1  Avas  sterile, 
2  were  multipara?,  5  had  given  birth  to  one  or  more  children.  Not 
one  of  the  multipara?  had  had  trouble  with  her  delivery,  and  in  no  one 
had  there  been  an  inflammatory  process  of  the  external  genitals.  Al- 
though Breisky  was  of  the  opinion  that  this  disease  was  the  result  of 
a  chronic  eczema,  yet  he  never  could  find  this  affection  in  his  cases.  In 
the  same  way  the  pruritus  seems  to  be  one  of  the  principal  causes  of 
this  disease,  and  yet  only  in  3  of  his  cases  was  it  present. 

Indeed,  the  etiology  of  this  disease  is  very  obscure.    It  occurs  with- 
out previous  existence  of  other  diseases  of  the  skin  of  the  vulva.     In 


Fig.  72  (Keeu).— '-The  labia  minora  are  fused  together  with 
the  labia  majora  and  scarcely  a  trace  of  them  is  to  be 

seen."— Eavogli  (page  207). 


DISEASES  OF   THE  SKIN  OF  THE   FEMALE   GENITALS 


209 


the  cases  reported  by  Orthmann  no  sugar  could  be  found  in  the  urine 
and  there  was  no  history  of  syphilis.  In  the  cases  reported  by  Reed,  in 
one  there  was  a  history  of  progressed  syphilis  in  early  life,  but  no  later 
manifestations  could  be  found.  So  that  it  has  been  established  and 
confirmed  by  Jjcwin  (Centralblatt  fur  Gyndlcologie,  1894)  that  the 
atrophy  of  the  vulva  is  not  of  a  syphilitic  origin.  Gonorrhoea  and  no 
specific  chronic  catarrh  are  considered  by  some  observers  as  probable 
etiological  factors.  This  disease  is  found  only  in  women  over  forty, 
which  would  identify  this  atrophy  with  trophic  changes  induced  by 
advancing  age.  Olshausen  lays  a  great  deal  of  stress  on  the  extirpation 
of  the  uterine  appendages  as  a  cause  of  this  atrophy,  which  relation  was 
found  in  one  of  Eeed's  cases.  In  one  of  Jevonsky's  cases  the  affection 
had  started  from  a  cicatrix  in  a  lacerated  perineum.  From  the  multi- 
plicity of  the  possible  causes  held  to  be  factors  in  this  disease,  it  seems 
that  no  one  must  be  considered  as  such,  and  Reed  prefers  the  theory 
that  the  peripheral  trophic  nerves  or  their  ganglia  are  to  be  consid- 
ered as  the  origin  of  this  disease. 

This  histologic  condition  of  the  skin,  as  found  by  H.  W.  Bettman 
in  Reed's  cases,  shows,  as  one  of  the  most  important  features,  a  marked 
hypersemia,  which  in  some  places  assumes  the  character  of  true  hemor- 
rhage. The  epi- 
dermis shows 
great  changes  ac- 
cording to  the 
.different  places  ; 
in  some  points 
it  is  hardened, 
thickened,  and 
hypertrophic,  in 
other  places  thin 
and  atrophic,  and 
in  other  places 
has  nearly  disap- 
peared (Fig.  73). 
The  corium  shows 
two  different  con- 
ditions. One  is 
due  to  the  exuda- 
tion and  infiltra- 
tion of  round  in- 
flammatory cells 
into  the  stroma  of 
the  corium,  and 
the  other  is  due  to 

the  sclerosis  and  atroy)hy  of  the  tissues.    These  are  two  different  condi- 
tions, one  the  consequence  of  the  other,  and  due  to  the  changes  of  the 
process.    In  the  first  condition  the  papillae  are  infiltrated,  in  the  second 
15 


Fig.  73  (Eeed). — "  The  epidermis  shows  great  changes  according 
to  the  different  places." — Ravogli. 


210  A   TEXT-BOOK  OF  GYNECOLOGY 

they  are  shrunken  and  have  nearly  disappeared.  In  the  same  case  the 
different  sections  show  a  difference  in  the  pathologic  alterations.  From 
the  ahove  observations  it  is  plain  that  the  anatomic  lesions  are  of  a 
different  character,  according  to  the  stage  of  the  disease.  In  the  begin- 
ning the  hypergemia  and  exudation  predominate  in  the  tissues,  later  the^ 
lesions  consist  of  a  thickening  and  shrinking  of  the  tissues  in  sclerosis. 

The  siihjedive  symptoms  of  this  disease  consist  at  first  of  painful 
points  and  a  painful  inelasticity,  which  are  impediments  to  the  copula- 
tive act.  In  the  later  period  there  is  a  loss  of  'sensation  in  the  entire 
diseased  area.  Itching  is  not  a  constant  symptom,  and  in  most  of  the 
cases  is  absent.  In  35  cases  referred  to  by  Ohmann-Dumesnil  13  cases 
were  troubled  with  itching  in  various  degrees.  In  5  cases  referred  to  by 
Orthmann  {Zeitschrift  filr  Gehurtshulfe  und  Gynakologie,  Stuttgart, 
1890)  only  1  patient  complained  of  an  itching  sensation.  In  6  cases  re- 
ferred to  by  Reed,  2  only  were  annoyed  in  that  way,  and  that  only  at 
the  beginning  of  the  affection. 

The  diagnosis  is  often  made  as  vaginismus  in  the  beginning  of  the 
affection,  but  careful  inspection  will  reveal  the  sensitive  areas  at  the 
ostium  vaginre  and  the  already  begun  shrinkage  of  the  vulvar  integu- 
ment. When  the  areas  of  atrophy  have  begun  it  is  possible  to  mistake 
the  disease  for  ichthyosis,  but  in  this  disease  there  are  adherent  scales,. 
which  are  never  found  in  kraurosis. 

In  reference  to  the  prognosis,  Tait  says  that  the  patient  should 
always  be  informed  that  the  progress  of  the  disease  will  extend  over- 
years, that  it  will  certainly  get  well  in  time,  but  that  treatment  from 
time  to  time  will  give  relief.  It  seems  that  the  recovery  alluded  to  is 
nothing  else  than  the  disappearance  of  the  subjective  symptoms.  We 
can  not  promise  recovery  to  the  patient  affected  with  this  disease  under 
any  circumstances. 

The  treatment  may  be  divided  into  palliative  and  curative.  The 
first  is  obtained  by  remedies  to  relieve  pain.  Carbolic  acid  in  the  form 
of  a  lotion,  on  account  of  its  anaesthetic  quality,  affords  some  temporary 
relief.  Tait  recommends  the  application  between  the  small  labia,  at 
bedtime,  of  a  piece  of  cotton  dipped  in  a  solution  of  neutral  acetate  of 
lead  in  glycerine,  as  capable  of  giving  relief.  A  mixture  of  tannin  and 
salicylic  acid  in  glycerine  has  been  used  in  the  same  way  with  good 
results.  Tait  condemns  cocaine  as  useless  and  irritating.  The  appli- 
cation of  nitrate  of  silver  in  stick  to  cauterize  the  degenerated  patches, 
so  as  to  obtain  a  good  cicatricial  tissue,  diminishes  the  sufferings,  but 
does  not  arrest  the  progress  of  the  disease.  Heitzmann  tried  to  scrape 
off  with  a  sharp  curette  the  hard  tissues  involved,  but  the  length  of  time 
this  process  takes,  and  the  poor  results  it  gives  do  not  commend  it. 
The  general  tonic  treatment  must  be  strongly  enforced  so  as  to  improve 
the  general  condition  of  the  patient. 

As  a  curative  treatment  Eeed  mentions  an  operative  process  by 
excision.  This  he  applied  in  an  incipient  case  of  kraurosis,  which  was 
limited  to  a  vascular  ring  around  the  ostium  vaginae.     The  mucous 


DISEASES  OP  THE  SKIN  OF  THE  FEMALE  GENITALS        211 


membrane  of  this  locality  was  completely  excised  in  the  form  of  an 
ellipse,  and  the  denuded  edges  were  brought  together  by  means  of  in- 
terrupted sutures.  The  patient  had  some  temporary  relief,  but  seven 
months  after,  the  disease  appeared  on  the  integument.  Martin,  as  re- 
ported by  Orthmann,  has  begun  the  method  of  a  complete  excision, 
which  must  be  applied  according  to  the  affected  parts,  removing  the 
tissue  thoroughly  and  approximating  the  edges.  In  this  way  eight  cases 
operated  upon  by  Martin 
completely  recovered.  The 
same  operation  in  the  hands 
of  Eeed  has  given  very  good 
results  (Fig.  74).  It  is  neces- 
sary not  to  operate  in  the  be- 
ginning of  the  affection,  be- 
cause the  process  is  not  yet 
limited,  and  it  is  liable  to 
spread,  in  spite  of  the  opera- 
tion. But  when  the  operation 
is  performed  at  the  time  that 
the  sclerotic  process  is  lim- 
ited, then  there  is  no  danger 
of  a  recurrence  of  the  disease. 
Vulvar  Adhesions. — The 
vulva  externally  consists  of 
integument  arranged  in  a 
series  of  folds  with  proximal 
surfaces.  The  fold  between 
the  labia  majora  and  the 
labia  minora  and  that  be- 
tween the  glans  of  the  cli- 
toris and  its  prepuce,  are 
striking  examples,  while  the 
surfaces  of  the  labia  majora 
lie  in  approximation,  particu- 
larly in  case  of  pudendal  re- 
dundancy. These  proximal 
surfaces  are  ordinarily  pre- 
vented from  becoming  ad- 
herent through  the  protective  influence  of  the  epithelial  layer  of  the 
skin.  There  occur  cases,  however,  of  antenatal  blending  of  these 
structures  (see  Malformations  of  the  Vulva);  others  in  which  adhe- 
sion occurs  speedily  after  birth;  and  still  others  in  which,  as  the 
result  of  desquamative  or  similarly  destructive  inflammation  of  the 
skin,  the  epithelium  becomes  destroyed  and  the  now  denuded  and  ap- 
proximated surfaces  unite.  Morris  {Transactions  of  the  American  Asso- 
ciation of  Obstetricians  and  Gynecologists,  1892)  called  attention  to 
the  frequent  adhesion  of  the  prepuce  to  the  glans  clitoridis,  a  condition 


Fig.  74. — "  The  same  operation  in  the  hands  of 
Keed  has  given  very  good  results." — Eavogli. 


212  A  TEXT-BOOK  OF  GYNECOLOGY 

which,  he  insists,  exists,  to  a  greater  or  less  extent,  in  80  per  cent 
of  Aryan  American  women.  He  finds  it  very  rare  among  the  negresses; 
and  looks  upon  its  occurrence  as  a  phase  of  evolutional  change.  When 
preputial  adhesions  are  extensive,  the  glans  clitoridis  and  the  impris- 
oned mucous  follicles  remain  comparatively  undeveloped,  but  attain 
their  normal  growth  after  liberation  of  the  adhesions.  When  these 
adhesions  are  slight  they  are  of  practically  no  clinical  importance,  but 
when  they  embrace  a  considerable  part,  or  the  whole,  of  the  glans  cli- 
toridis, they  cause  profound  disturbances;  so  much  so,  that  Morris  con- 
siders that  preputial  adhesions  probably  form  the  most  common  single 
factor  in  invalidism  in  young  women.  Bacon  {American  Gynecological 
and  Ohstctrical  Journal)  summarizes  his  observations  and  experience  of 
preputial  adhesions  in  the  female,  with  the  statement  that  they  are 
prone,  by  the  irritation  they  induce,  to  cause  masturbation  and  the 
various  neuroses;  and  that  the  prevention  by  them  of  the  development 
of  the  glans  clitoridis  frequently  results  in  eroticism.  The  damaging 
influence  of  these  adhesions  is  experienced  relatively  more  in  the  child 
than  in  the  adult,  for  the  reason  that  in  the  former  the  reflex  nervous 
centres  are  less  under  the  control  of  inhibitory  impulses,  and  peripheral 
irritation  consequently  produces  disturbances  that  would  not  be  ex- 
perienced in  maturer  years.  The  treatment  of  this  condition  consists  in 
breaking  u]i  the  adhesions  as  soon  as  they  are  found,  or  particularly  as 
soon  as  they  are  recognised  as  causes  of  mischief.  Bacon  is  of  the  opin- 
ion that  every  female  child  should  be  examined,  and  the  clitoris,  if 
found  adherent,  should  be  liberated  in  the  earlier  weeks  of  life.  The 
operation  for  this  purpose  consists  in  peeling  the  prepuce  off  the  glans 
by  means  of  a  grooved  director  or  other  blunt  instrument,  and  in  keep- 
ing the  area  dressed  antiseptically  until  it  heals,  care  being  taken  fre- 
quently to  separate  the  proximal  surfaces  to  prevent  readhesion.  In 
labial  adhesions,  partieularl}^  when  these  are  of  antenatal  occurrence, 
the  structures  are  frequently  so  intimately  fused  as  to  defy  separation. 
In  certain  of  these  cases  the  labia  minora  will  be  found  implanted  upon 
the  surfaces  of  the  labia  majora  so  intimately  that  upon  retracting 
the  latter  the  former  can  be  detected  only  in  outline.  This  condition  is 
rarely  of  any  clinical  importance.  It  may,  however,  give  rise  to  local 
disturbance  from  the  accumulation  of  sebaceous  matter  secreted  by  the 
rudimentary  follicles  that  are  incarcerated  within  the  adhesions.  When 
this  occurs  the  accumulation  should  be  liberated  by  incision,  while  at 
the  same  time  an  eft'ort  should  be  made  to  break  up  the  fusion. 


CHAPTER    XVIII 

HYPERTROPHIC   AND   HYPERPLASTIC   DISEASES  OF   THE 
PUDENDAL  ORGANS 

Hypertrophy  of  the  clitoris — Condylomata— Elephantiasis — Polypi — Treatment. 

The  hypertrophic  and  hyperplastic  diseases  of  the  pudendal  organs 

are,  as  a  rule,  acquired.  Congenital  hypertrophy  of  the  vulva  is  com- 
paratively rare  and  is  confined  to  single  parts  of  the  pudendum.  The 
parts  usually  found  enlarged  in  congenital  hypertrophy  are  the  labia 
minora  and  the  clitoris.  In  the  case  of  the  former,  it  is  often  difficult  to 
decide  at  the  time  when  the  observation  is  made  whether  one  is  deal- 
ing with  a  true  congenital  condition  or  with  one  acquired  by  accidental 
pathologic  processes.  Manipulations  are  employed  by  certain  tribes 
to  bring  about  a  hypertrophy  of  the  labia  minora.  As  is  well  known, 
the  South  African  Hottentots,  by  certain  methods  practised  on  their 
female  children,  produce  that  enormous  hypertrophy  of  the  labia 
minora  described  as  the  "  Hottentot  apron." 

Hypertrophy  of  the  clitoris,  while  occasionally  an  acquired  condi- 
tion, is  probably  the  most  common  form  of  congenital  hypertrophy  of 
the  pudendum.  A  large  number  of  cases  of  this  kind  have  been  de- 
scribed, one  of  the  most  remarkable  by  Fehling,  who  reported  the  case 
of  a  girl  of  twenty-one  years  with  a  clitoris  five  inches  long,  as  thick  as 
a  thumb,  and  with  a  glans  one  inch  long.  Extensive  congenital  hyper- 
trophy of  the  clitoris  is  frequently  combined  with  atresia  of  the  labia 
minora,  descent  of  the  ovaries,  and  other  anomalies  obscuring  the  true 
sex  of  the  individual,  and  bringing  about  the  condition  known  as  female 
pseudo-hermaphrodism.  (See  Malformations  of  the  Vulva.)  This  con- 
dition is  simply  one  in  which,  owing  to  anomalous  development,  the 
pudenda  simulate  to  a  certain  degree  the  male  organs  of  generation. 

Of  the  acquired  hypertrophies  and  hyperplasias,  there  are  two  im- 
portant groups  of  morbid  conditions  which  have  to  be  considered, 
viz.,  the  condylomata  and  elephantiasis.  Both  of  these  are  more  prop- 
erly to  be  looked  upon,  not  as  truly  neoplastic  formations,  but  as  hyper- 
trophic and  hyperplastic  diseases,  since  they  develop  upon  an  inflam- 
mn,toi-y  basis. 

Condylomata  ai*e  usually  present  as  elevated  condylomata  (C.  acu- 
minata), more  I'arely  as  broad  condylomata  (C.  lata).  They  develop 
on  tin  iiifl;iiiirii;ilory  basis,  which  may  be  sim])le,  gonorrhroic,  or  syphi- 
lilic     ( 'ofi'lyloinuta,  are,  liowever,  not  to  be  considered  as  a  specific 

213 


214  A  TEXT-BOOK  OF  GYNECOLOGY 

process,  but  as  a  secondary  hypertrophy,  developing,  as  the  case  may 
be,  on  either  a  specific  or  a  nonspecific  soil.  In  an  early  stage  these 
hypertrophies  form  small,  pointed  elevations,  warty  in  character.  They 
are  found  on  the  labia  niajora  and  labia  minora,  the  clitoris,  the  mons 
veneris,  and  they  spread  not  infrequently  over  the  skin  of  the  peri- 
neum, around  the  anus,  and  over  the  inner  surfaces  of  the  thighs. 
They  are  first  found  united  in  smaller  groups,  with  spaces  between 
them  free  from  excrescences.  Later  on,  they  often  become  confluent, 
forming  large  masses  which  hide  entirely  from  view  the  whole  of  the 
pudendum,  the  latter  being  then  covered  by  an  uneven,  irregular, 
ragged,  papillomatous,  or  cauliflower  mass  (Fig.  75),     In  colour  they 


Fig.  75. — "They  become  eontliunt.  l^iming  large  masses  which  hide  from  view  the  whole 
of  the  pudendum." — Herzog. 

may  vary  from  a  grayish-white  to  a  pink  or  rose-red.  The  surface  may 
be  dry  and  shiny,  or  it  may  be  moist.  It  is  usually  not  ulcerated,  unless 
it  has  been  subjected,  in  consequence  of  very  improper  care,  to  a  good 
deal  of  friction  or  other  irritation.  One  of  the  notable  features  of  these 
condylomatous  masses  is  their  very  rapid  growth  during  the  period  of 
gestation.  This  is  evidently  due  to  the  increase  of  the  blood  supply  to 
the  genital  organs  in  pregnancy. 

Microscopic  examination  of  condylomatous  masses  shows  that  they 
consist  mainly  of  enormous  hypertrophies  of  the  papillary  layer  of  the 
skin.  The  papillae,  normally  short  and  simple,  become  elongated  and 
branched  like  a  tree;  they  divide  dichotomously  or  in  a  digitate  manner. 
These  hypertrophied  papillae  consist  of  connective-tissue  fibres  and 
round,  oval,  or  stellate  cells,  supporting  a  network  of  blood  vessels.    The 


HYPERTROPHIC  AND   HYPERPLASTIC   DISEASES  215 

:finest  papillary  branches  are  mainly  composed  of  blood  vessels  with 
only  scanty  connective-tissue  fibres  and  cells  as  a  stroma.  The  hyper- 
trophic fibrillar  connective  tissue  frequently  shows  an  extensive  round- 
cell  infiltration  consisting  of  polynuclear  leucocytes  and  mononuclear 
lymphocytes.  The  epithelial  layer  covering  these  complicated  hyper- 
trophic papillaa  is  thickened.  The  thickening  is  noticeable  in  the  Mal- 
pighian  layer,  or  stratum  germinativum,  as  well  as  in  the  older  more 
.superficial  strata. 

Condylomatous,  cauliflower  masses  of  the  vulva,  may  be  confounded 
with  carcinomata  of  the  vulva,  which  are  also  apt  to  form  cauliflower 
excrescences.  Besides  the  clinical  features  which  have  to  be  consid- 
ered, a  careful  microscopic  examination  of  a  series  of  sections,  made 
vertically  in  the  direction  of  the  papillary  layer,  can  always  clear  up  the 
diagnosis.  We  have  in  carcinoma  as  the  most  prominent  histological 
feature  the  great  proliferation  of  the  epithelia  of  the  skin.  These  pro- 
liferating cells  form  alveolar  or  tubular  nests  which  are  surrounded  by 
connective  tissue.  In  condylomata,  on  the  other  hand,  we  have  the 
great  hypertrophy  of  the  connective  tissue,  and  the  hypertrophic  con- 
nective-tissue masses  are  surrounded  by  layers  of  epithelial  cells. 

There  occur  also  certain  small  excrescences  on  the  pudendum,  due 
to  frequent  masturbatory  manipulations,  which  must  not  be  mistaken 
for  what  is  to  be  classified  as  a  true  condyloma  of  the  vulva.  The 
excrescences  of  this  type,  which  may  to  some  extent  simulate  an  early 
stage  of  condylomata  acuminata,  are  generally  found  on  the  mucous 
membrane  between  the  margin  of  the  hymen  and  the  labia  minora,  and 
also  in  the  neighbourhood  of  the  external  meatus  of  the  urethra.  They 
are  easily  distinguished  from  true  condylomata  by  the  fact  that  they 
are  small  in  size,  simple,  and  not  branched.  They  occur  on  the  mucous 
surfaces  only,  and  do  not  spread  to  the  epidermal  surfaces  of  the  vulva 
or  neighbouring  parts.  They  are  never  infectious  in  nature,  and  occur 
most  frequently  in  virgins  of  a  hysterical  disposition.  Keeping  these 
points  in  view,  one  is  not  likely  to  mistake  these  masturbatory  excres- 
cences for  true  condylomata. 

The  treatment  of  the  venereal  warts  consists  in  their  removal.  This 
is  done  either  by  surgical  means  or  by  caustics;  the  first,  however,  is 
always  preferable  to  the  second. 

In  case  of  small  warts  on  the  female  genitals,  they  must  first  be 
washed  with  a  solution  of  bichloride  (1  to  1,000),  or  with  a  solution  of 
carbolic  acid  (1  to  100).  After  drying  them  with  cotton  they  are  soaked 
with  a  cocaine  solution  (5  per  cent),  and  then  they  are  scraped  off 
with  a  sharp  curette,  removing  the  small  growths  completely.  On  ac- 
count of  the  richness  in  blood  vessels  of  the  warts  at  their  points  of  in- 
sertion thoy  bleed  freely.  The  bleeding  is  stopped  by  the  application  of 
a  tampon  (]it)ped  in  a  saturated  solution  of  perchloride  of  iron.  With 
this  process  llavogli  has  obtained  very  good  results,  and  he  states  that 
very  seldom  has  he  seen  a  recurrence.  In  case  the  warts  should  grow  up 
again,  it  is  better  to  destroy  them  at  once  by  toiu;]iing  them  with  a 


216  A  TEXT-BOOK  OF   GYNECOLOGY 

solution  of  ehloracetic  acid,  lactic  acid,  or  acid  nitrate  of  mercury.  Tay- 
lor recommends  the  use  of  collodion  containing  bichloride  of  mercury, 
30  grains  to  the  ounce,  or  salicylic  acid,  1  drachm  to  the  ounce. 

Caustics  are  used  independently  of  the  curetting  to  obtain  the 
destruction  of  the  venereal  warts.  A  strong  solution  of  chromic  acid, 
from  1  to  4  drachms  to  the  ounce  of  water,  has  been  applied^  but 
the  pain  which  results  is  absolutely  unbearable,  and  the  cauteriza- 
tion is  not  limited,  affecting  also  the  healthy  skin.  J.  W.  White  re- 
ferred to  the  case  of  a  woman  who  died  in  collapse  in  twenty-seven 
hours  from  the  ap^olication  of  this  solution  on  warts  affecting  the  vulva 
and  the  anus.  {Journal  of  Cutaneous  and  Genito-urinary  Diseases, 
1889.) 

When  the  condylomata  have  attained  an  extraordinary  develop- 
ment, it  is  necessary  to  remove  them  with  the  galvano-cautery  loop, 
by  which  means  we  can  prevent  loss  of  blood. 

When  there  are  warts  round  the  meatus  of  the  urethra,  care  must 
be  taken  not  to  cause  any  laceration  or  wound,  which  may  be  the  origin 
of  a  scar  strieturing  the  meatus. 

Taylor  recommends  the  application  of  a  powder  of  equal  parts  of 
calomel  and  salicylic  acid,  whicli  has  often  given  him  very  satisfactory 
results. 

Caesar  Boeck  {Monatshefte  filr  prakiisclie  Dermatologie,  1886)  rec- 
ommends the  application  of  a  watery  solution  of  resorcin  on  the  con- 
dylomata, especially  when  they  have  a  tendency  to  recurrence.  He  vises 
also  a  powder  of  resorcin,  eight  parts,  and  bismuth  subnitrate  and  boric 
acid,  one  part  each,  to  dust  the  condylomata,  claiming  prompt  and 
effective  results. 

The  following  formula,  which  is  applied  after  the  warts  have  been 
well  bathed  with  a  solution  of  bichloride,  as  above  described,  has  been 
also  praised: 

^  Acidi  salicylici,  )                                                              _.  ^^^  . 

Chrysarobini,       ) *     '' 

Collodii  flexilis §j. 

M.     To  be  applied  twice  a  day. 

In  Ravogii's  clinic  he  has  found  formaldehyde  very  useful,  which 
he  applies  in  a  strength  of  from  8  per  cent  to  42  per  cent,  as  it 
comes  in  commerce.  The  application  of  pure  formaldehyde  is  rather 
painful  and  requires  the  previous  us'e  of  cocaine  to  diminish  the  pain. 
One  or  two  applications  have  been  sufficient  to  cause  the  condyloma  to 
become  necrotic  and  slough  off.  It  is  necessary  to  direct  attention  to 
the  condition  of  the  vagina  and  of  the  womb,  to  be  sure  that  gonorrhoea 
has  entirely  ceased. 

Elephantiasis  vulvae  may  be  defined  as  a  pale  whitish  tumour  for- 
mation, or  swelling,  arising  from  the  labia  majora  and  labia  minora  and 
from  the  clitoris.  It  is  by  no  means  an  easy  matter  to  properly  classify 
elephantiasis  vulvae.    There  is  practically  nothing  known  as  to  the  true 


HYPERTROPHIC   AND   HYPERPLASTIC   DISEASES 


217 


etiology  of  this  affection,  but  it  appears  that  most  cases  of  elephanti- 
asis deyelop  on  an  inflammatory  soil.  It  is  certain  that  all  fully  devel- 
oped and  characteristic  cases  histologically  represent  an  immense  hyper- 
trophy of  connective-tissue  elements.  Hence  elephantiasis  vulvae  is  here 
classified  under  hypertrophic  diseases  of  the  pudendal  organs.  It  must, 
however,  not  be  forgotten  that  elephantiasic  formations  in  other  parts  of 
the  skin  have  been  shown  to  be  true  neoplasms,  lymphangeiomata — i.  e., 
tumours  consisting  of  newly  formed  lymph  vessels  and  other  lymphatic 
elements. 

Elephantiasis  vulvse  may  develop  from  a  single  place,  or  it  may  be 
multiple  from  the  start,  the  single  component  parts  becoming  confluent 
later  on  in  the  course  of  the  disease.  The  connective-tissue  prolifera- 
tion in  elephantiasis  leads  to  the  largest  tumour  formations  that  are 
found  in  connection  with  the  pudendal  organs.  In  its  incipient  stages, 
elephantiasis  can  not  be  distinguished  clinically  and  macroscopically 
from  any  simple  noninflammatory  hypertrophy,  but,  later  on,  the  enor- 
mous size  of  the  hypertrophic  for- 
mation distinguishes  it  clearly 
from  any  other  known  condition. 
In  growing,  the  tumour  gets  so 
heavy  and  large  that  it  becomes 
pedunculated  in  consequence  of 
its  own  weight,  the  main  mass 
often  reaching  down  to  the  knees. 
While,  with  us,  elephantiasis 
vulvge  is  a  comparatively  rare  dis- 
ease, it  is  quite  frequently  met 
with  in  some  of  the  Eastern  and 
tropical  countries.  The  different 
forms  of  this  affection  have  been 
variously  classified  according  to 
certain  prominent  morphological 
characters.  Tumours  showing 
even  surfaces  have  been  called  ele- 
phantiasis phrosa,  while  those 
showing  a  warty  surface  have  been 
called  papillary  elephantiasis  (Eig. 
76).  Another  classification  makes 
three  subdivisions,  as  follows: 
Smooth  surfaced  tumours  cov- 
ered by  skin  which  is  not  mate- 
rially different  from  the  surrounding  epidermis — elephantiasis  qlabra; 
tumours  showing  an  irregularly  nodular  surface — elephantiasis  tuherosa; 
and  tumours  with  a  surface  showing  numerous  small  warts  and  excres- 
cences— elephantiasis  condylowaiasa. 

The  microscopic  picture  of  elephantiasis  vulva?  varies  according  to 
I  he  variety  of  ili(!  liinionr  and  its  stage  of  development.     In  the  smooth 


Fig.  76.—"  Tumours  showing  a  warty  surface 
have  been  c&WeA  papillary  elephantiasis.'''' 
— Herzog. 


218 


A  TEXT-BOOK  OF  GYNECOLOGY 


and  tuberous  forms  the  great  mass  of  tlie  tumour  consists  of  a  tissue 
composed  of  old  fibres  quite  poor  in  nuclei.  This  connective  tissue 
shows  a  marked  oedematous  infiltration  and  is  sparingly  vascularized. 
Capillaries  and  small  arteries  exhibit  a  perivascular  round-cell  infiltra- 
tion. The  papillary  body  of  the  derma  is  poorly  developed,  the  epi- 
thelial layers  are  thinned  out,  sebaceous  and  sweat  glands  are  present 
in  small  numbers  only,  and  even  absent  over  large  territories.  While 
in  the  first  two  forms  described,  the  papillary  body  is  not  hypertrophic, 
but  rather  atrophic,  the  third  form,  the  elephantiasis  condylomatosa,  is 
characterized,  like  the  true  condylomata,  by  a  well-marked  hypertrophy 
of  the  papillae  of  the  skin.  In  all  three  forms,  when  well  advanced, 
there  is  also  a  great  deal  of  thickening  of  the  subcutaneous  connective 
tissue,  in  which  sometimes  evidences  of  new  formation  of  lymph  vessels 

may  be  found.  Pozzi 
and  other  French  au- 
thors describe  the  his- 
tory of  elephantiasis 
as  presenting  a  num- 
ber of  stages.  The 
hypertrophied  skin, 
according  to  their  de- 
scription, first  takes 
on  an  embryonal  type, 
containing  also  large 
lymph  spaces  like 
those  found  in  true 
lymphangeiomata. 
There  occurs  then, 
after  an  oedema  has 
been  established,  an 
extensive  lymph  stasis 
and  infiltration  of  the 
tissues  with  lymph. 
In  this  stage,  there 
are  also  found  in  the 
elephantiasic  tissues 
lymph  glands  in  a 
state  of  fibrous  de- 
generation. The  last 
stage  is  represented 
by  an  enormous  thick- 
ening of  the  skin, 
which,  according  to  the  French  authors,  from  whom  others  differ,  com- 
prises all  the  layers.  According  to  the  view  now  generally  adopted,  the 
thickening  in  most  cases  is  chiefly  confined  to  the  subpapillary  and  sub- 
cutaneous layers. 

Superficial  ulcerations  not  infrequently  occur  when  the  tumour 


Fig.  77.- 


-"  The  prepuce,  now  divided  into  two  flaps,  is  cut 
away." — Eeed  (page  220). 


HYPERTROPHIC  AND  HYPERPLASTIC  DISEASES 


219 


has  attained  a  larger  size,  and  sometimes  the  l5rmph  vessels  are  so 
greatly  enlarged  and  dilated  that  they  produce  a  lymphorrhoea  from  the 
ulcerating  portions. 

Tlie  etiology  of  elephantiasis  is  still  very  obscure.  Patients  suffer- 
ing from  elephantiasis  vulvse  not  infrequently  present  the  cicatrices  of 
inguinal  buboes  or  scars  on  the  vulva.  Frequently  a  history  of  syphilis 
may  be  obtained,  and  undoubted  syphilitic  manifestations  may  coexist 
with  elephantiasis.  The  latter,  however,  can  not  be  eradicated  by  an 
antisyphilitic  treatment,  though  one  sees  occasionally  a  transitory  im- 
provement after  the  free  exhibition  of  the  iodides. 

Polypi  of  the  vulva,  which  authors  frequently  classify  under  neo- 
plasms of  the  pudendal  organs,  belong  more  properly,  if  one  excludes  the 
true  fibromata,  to  the  hypertrophic  and  hyperplastic  diseases.  These 
polyps,  usually  found  in  the  neighbourhood  of  the  external  meatus,  rep- 
resent hypertrophies  of  the  mucous  membrane  of  the  vestibule.  They 
vary  from  the  size  of  a 
pea  to  that  of  a  hazel- 
nut, are  soft  and 
pinkish  in  colour, 
smooth  or  mulberry- 
like, sessile  or  pe- 
dunculated. Micro- 
scopically, they  show 
a  loose  fibrillar  con- 
nective tissue  with 
round  -  cell  infiltra- 
tion, are  covered  by 
squamous  epithelial 
cells,  and  often  con- 
tain glandular  spaces 
lined  with  columnar 
epithelium.  They  are 
due  to  inflammatory 
irritations,  and  it  has 
recently  been  found 
that  they  sometimes 
contain  gonococci. 

The  treatment  of 
hypertrophic  and  hy- 
perplastic diseases  of 
the  pudendal  organs 
is  almost  exclusively 
surgical.  Polypi 
should  be   treated   in 

the  same  manner.  Acquired  enlargement  of  the  clitoris,  when  a 
source  of  persistent  local  or  constitutional  disturbance,  should  be 
treated  by  extirpation.      (See   Clitoridectomy.)     E.    C.   Dudley  looks 


Fig.  78.- 


-"  The  exposed  raw  surfaces  are  closed  by  a  series 
of  fine  catgut  sutures."— Keed  (page  220). 


220  A  TEXT-BOOK  OP  GYNECOLOGY 

upon  acquired  hypertrophy  of  the  clitoris,  and  more  particularly  its 
prepuce,  as  being  ordinarily  the  result  of  masturbation.  Those  cases 
in  which  the  clitoris  is  moderately  enlarged  and  surrounded  by  an 
abundance  of  loose,  flabby,  redundant  preputial  skin,  he  treats  by  what 
he  calls  circumcision.  The  prepuce  is  slit  up  on  the  dorsum  of  the  cli- 
toris, as  would  be  done  in  a  similar  operation  on  the  male,  or  as  is  done 
in  the  initial  step  of  clitoridectomy.  The  prepuce,  now  divided  into 
two  flaps,  is  cut  away  by  seizing  first  one  flap  and  then  the  other  with 
a  forceps  and  cutting  it  ofl^  at  its  base  with  the  scissors  (Fig.  77).  The 
exposed  raw  surfaces  are  closed  by  a  series  of  fine  catgut  sutures 
(Fig.  78). 


CHAPTEE    XIX 

NEOPLASMS   OF   THE   EXTERNAL.  GENITAL   ORGANS 

(A)  Benign  neoplasms  of  the  pudendum:  Varices,  fibrorayomata,  pure  myomata, 
myxomata,  lipomata,  enchondromata,  neuromata,  cysts — Benign  neoplasms  of 
the  vagina:  Cysts,  fibromata — Treatment — (B)  Malignant  neoplasms  of  the 
pudendum:  Carcinomata,  sarcomata,  melano-carcinomata — Malignant  neo- 
plasms of  the  vagina :  Sarcomata,  carcinomata — Treatment :  Excision — Clitori- 
dectomy — Extirpation  of  the  vagina. 

Benign  Neoplasms 

The  pudendal  organs,  like  other  part.s  of  the  female  genitalia,  may 
become  the  seat  of  neoplastic  diseases.  These  neoplasms,  from  a  histo- 
pathological  standpoint,  are  to  be  divided  into  connective-tissue  tumours 
and  epithelial  new  growths.  For  practical  purposes  it  seems  advisable 
here  to  separate  the  nonmalignant  from  the  malignant  new  growths. 
Among  the  former  there  will  be  included  in  this  consideration  some 
pathologic  conditions  which,  strictly  speaking,  do  not  belong  to  the 
tumours  at  all. 

Benign  Neoplasms  of  the  Pudendum. — It  is  a  matter  of  doubt 
whether  true  hemangeiomata — i.  e.,  tumours  developing  from  and  char- 
acterized by  a  new  formation  of  blood  vessels — have  been  observed  in 
the  pudendal  organs.  There  are  to  be  found,  however,  in  literature  very 
few  reports  according  to  which  true  neoplastic  angeiomata  have  been 
observed  in  the  vulva. 

The  condition  frequently  found  and  described  as  varicose  tumour  of 
the  vulva  is  not  a  genuine  neoplasm,  but  represents  varicosities  due 
either  to  local  or  to  general  disturbances  of  circulation  (Fig.  79).  All 
circulatory  disturbances  of  the  lower  half  of  the  female  body  have  a 
tendency  to  lead  to  marked  manifestations  in  the  vulva,  its  great  sup- 
ply of  blood  vessels  favouring  very  much  venous  stasis  and  the  for- 
mation of  varicosities.  Pregnancy  is  a  most  fruitful  cause  of  enlarged 
congested  veins  in  the  pudendal  organs.  We  then  find  the  veins  of 
the  labia  majora  greatly  congested  and  dilated,  and  they  rise  as  promi- 
nent purple  swellings  over  tbe  level  of  the  surrounding  skin.  Large 
tumours  of  the  ovaries,  as  well  as  fibromyomata  of  the  uterus,  may 
produce  similar  swellings.  Valvular  lesions  of  the  heart,  as  well  as 
nephritis,  cause  enormous  o'deiria  of  the  vulva  and  produce  swellings 
of  1lic  hi  bin   iii;ijor;i  that  attain  at  times  great  dimensions.     Chronic 

221 


222 


A  TEXT-BOOK  OP  GYNECOLOGY 


inflammatory  conditions  in  the  pelvis  also  lead  occasionally  to  vari- 
cosities of  the  piidendiun.  The  greatly  dilated  and  enlarged  veins  may 
imdergo  secondary  changes,  as  phlebitis  and  fatty  or  calcareous  de- 
generation, when  there  may  occur,  even  in  the  absence  of  any  appre- 
ciable force  or  insult, 
spontaneous  hemor- 
rhage into  the  tis- 
sues ;  a  hematoma 
vulvce  is  thus  estab- 
lished. (See  Inju- 
ries of  the  Vulva.) 

Among  the  be- 
nign true  tumours 
of  the  vulva  the 
fibromata  and  filro- 
myomata  are  prob- 
ably the  most  com- 
mon, though  they 
are  by  no  means  fre- 
quently met  with. 
These  new  growths 
take  their  origin 
from  the  subcuta- 
neous connective  tis- 
sue of  the  labia  ma- 
jora  and  labia  mino- 
ra, more  rarely  from 
the  clitoris.  They 
form  hard,  somewhat 
nodular,  roundish, 
oval,  or  elongated 
masses,  covered  by 
normal  skin.  Histo- 
logically these  tumours  consist  of  newly  formed,  wavy,  fibrous,  connect- 
ive tissue,  very  poor  in  nuclei,  which  is  surrounded  by  a  capsule  made 
up  of  a  condensed  tissue  of  the  same  type.  The  skin  is  generally 
somewhat  movable  over  the  capsule  and  is  not  much  changed  in  its 
structure  and  appearance.  The  tumour  proper  frequently  contains, 
besides  fibrous  connective  tissue,  nonstriated  involuntary  muscle  fibres 
or  cells,  so  that  the  neoplasm  assumes  the  character  of  a  fibromyoma. 

Pure  myomata  of  the  vulva  are  very  rare,  though  they  have  been 
observed  occasionally.  Wliile  the  tumours  of  the  fibromyomatous  group 
are,  as  a  rule,  firm,  hard,  and  solid,  there  may  occur  in  them,  in  con- 
sequence of  lymph  stasis,  lymphangeiectatic  spaces  of  large  extent.  In 
a  case  of  this  kind,  diagnosis  between  fibromyoma  and  elephantiasis- 
may  be  impossible  without  the  aid  of  a  microscopic  examination.  The 
latter,  however,  will  clear  up  the  diagnosis.     The  fibromata  show  a 


Fig.  79. — ''The  coudition  frequently  found  and  described  as 
varicose  tumours  of  the  vulva." — Herzog  (page  221). 


NEOPLASMS  OP   THE  EXTERNAL  GENITAL  ORGANS  223 

well-circumscribed  proliferation  and  new  formation  of  connective  tis- 
sue, while  in  elephantiasis  the  hypertrophic  processes  of  the  connective 
tissue  are  diffuse  and  infiltrating,  and  there  are  also  characteristic 
changes  in  the  skin,  which  is  practically  unchanged  in  fibroma  and 
fibromyoma. 

These  tumours,  as  has  been  shown  recently,  frequently  do  not  arise 
from  the  pudendal  organs  proper,  but  from  the  round  ligament,  and 
only  later  on  in  their  growth  and  development  descend  into  and  en- 
croach upon  the  pudendum.  Fibrous  tumours  starting  primarily  from 
the  fascia  of  the  pelvis  may  likewise  in  the  course  of  their  development 
and  growth  descend  into  the  pudendum  and  present  as  tumours  of  the 
latter. 

The  fibromata  and  fibromyomata  of  the  pudendal  organs  have  been 
observed  at  all  ages  from  about  the  age  of  puberty  until  long  after  the 
climacteric  period.  They  may  be  single  or  multiple.  Their  growth  is 
usually  slow,  but  they  may  become  very  large  in  size,  reaching  down 
to  the  knees,  and  weighing  as  much  as  fifteen  pounds  and  more.  When 
these  fibrous  tumours  attain  a  large  size  they  have  a  tendency  to  become 
pedunculated.  Some  fibromata  show  a  pedunculated  character  from  the 
start,  forming  small,  elongated  projections  from  the  integument  of  the 
labia  majora.  They  have  been  described  as  fibroma  molluscum  or  mol- 
luscum  pendulum  of  the  vulva. 

The  larger  fibromata  of  long  standing  are  apt  to  become  ulcerated 
on  the  surface  by  pressure  and  lack  of  proper  care  and  cleanliness. 
They  are  also  liable  to  undergo  calcareous  degeneration.  Another  sec- 
ondary change  to  which  they  may  become  subjected,  consists  in  an 
extensive  oedematous  infiltration,  in  consequence  of  which  the  fibres 
composing  the  neoplasm  become  pushed  apart.  Such  tumours  are  not 
hard,  but  rather  soft;  they  may  even  show  pseudo-fluctuation,  and 
microscopically  their  tissue  looks  very  much  like  a  myxoid  degenera- 
tion, though  it  really  only  represents  an  extensive  oedematous  infiltra- 
tion. Fibromata  so  changed  have  frequently  been  reported  as  myxo- 
mata  or  myxofibromata. 

Lipomata  of  the  vulva  are  rare.  They  are  occasionally  found  in  the 
mons  veneris  or  in  the  labia  majora  and  form  well-differentiated  round- 
ish tumours.  They  are  very  much  softer  than  fibromata,  and,  like  them, 
are  sometimes  pedunculated.  Like  the  fibromata,  the  lipomata  of  the 
vulva  have  a  tendency  to  increase  rapidly  in  size  during  pregnancy,  to 
again  somewhat  decrease  after  the  termination  of  gestation.  A  very 
few  cases  of  congenital  lipoma  of  the  labium  majus  have  been  reported. 

Enchondromata  and  neuromata  of  the  vulva  have  been  described,  but 
since  these  reports  are  not  based  upon  a  microscopic  examination,  they 
can  not  be  accepted  as  valid  evidence  of  the  actual  occurrence  of  such 
tumours. 

C't/.s/.s  of  the  vulva  may  here  receive  some  mention,  although  they 
are  almost  without  exception  not  true  neoplasms,  but  mere  retention 
cysts.    The  cysts  found  most  frequently  in  the  region  of  the  vulva  are 


224  A  TEXT-BOOK  OF  GYNECOLOGY 

developed  from  the  glands  of  Bartholin,  either  from  the  gland  proper 
or  from  its  secretory  duct.     (See  Vulvo-vaginal  Gland.) 

Other  cysts  similar  in  character  to  those  of  the  vulvo-vaginal  gland 
take  their  origin  from  Gartner's  duct,  which,  as  is  well  known,  occa- 
sionally extends  downward  into  the  vulva. 

There  are  also  sometimes  found  in  the  labia  majora  atheromatous 
cysts  and  dermoids.  They  are  lined  internally  by  squamous  and  some- 
times by  cylindrical  epithelium;  acinous  glandular  structures  have  been 
described  in  connection  with  such  cysts.  Small,  yellowish,  translucent 
cysts,  observed  not  unconmionly  on  the  hymen,  are,  as  their  structure 
and  contents  show,  retention  cysts  of  sebaceous  glands.  There  have 
also  been  observed  on  the  hymen  small  multiple  cysts  of  the  character 
of  lymphangeiectatic  formations.  Aside  from  the  cysts  of  the  vulvo- 
vaginal glands  due  to  gonorrhoeal  infection,  cysts  of  the  pudendal 
organs,  as  before  described,  have  no  important  practical  bearing;  they 
are  generally  discovered  only  accidentally,  not  giving  rise  to  any  symp- 
toms. In  rare  cases  larger  cysts  of  this  type  may  give  rise  to  slight  in- 
conveniences in  consequence  of  their  size. 

Benign  Neoplasms  of  the  Vagina. — Cysts  of  the  vagina  are  not  so 
very  uncommon.  According  to  the  statistics  of  Neugebauer,  they  are 
found  in  one  of  every  six  hundred  women  presenting  themselves  for 
examination.  They  are  usually  solitary,  and  when  multiple  rarely 
more  than  three  or  four  are  present,  which  tend  to  arrange  themselves 
in  rows.  Most  frequently  they  are  found  in  the  upper  part  of  the 
vagina,  especially  growing  from  the  anterior  wall,  though  they  may 
develop  in  the  lateral  walls,  as  well  as  in  the  lower  part  of  the  vagina. 
They  vary  in  size  from  a  pea  to  a  hen's  egg,  though  Yeit  has  reported 
a  case  in  which  the  cyst  reached  the  size  of  a  foetal  head.  In  most 
instances,  however,  they  tend  to  grow  slowly,  and  rarely  reach  a 
large  size. 

Age  appears  to  have  no  influence  in  their  etiology,  as  they  occur 
in  virgins  as  well  as  in  women  who  have  borne  children.  Many  the- 
ories have  been  advanced  in  explanation  of  the  origin  of  these  cysts. 
Huguier  and  Guerin  thought  they  always  grew  from  glands  which 
were  present  in  the  walls  of  the  vagina.  In  later  years  the  tend- 
ency has  been  to  regard  all  cysts  of  the  vagina  as  having  their  origin 
in  the  remains  of  the  WolflHan  bodies.  While  a  certain  proportion  of 
cysts  no  doubt  originate  in  this  manner,  this  theory  fails  to  explain  the 
origin  of  many  cysts  which  develop  in  locations  remote  from  such 
embryonal  structures  and  which  are  very  superficial.  More  recently 
Preuschen  was  able  to  demonstrate  the  actual  existence  of  ductlike 
glands  in  a  number  of  cases  examined  post-mortem,  which  were  lined 
with  columnar  epithelial  cells,  from  which  fact  he  attributed  to  those 
cysts  occurring  in  locations  other  than  the  anterior  or  lateral  walls  of 
the  vagina  a  glandular  origin.  It  is  evident,  therefore,  that  we  must 
admit  the  glandular  theory  as  explaining  the  origin  of  a  certain  propor- 
tion of  smaller  cysts,  while  most  of  the  larger  cysts  develop  from  the 


NEOPLASMS  OF  THE  EXTERNAL  GENITAL  ORGANS 


225 


•embryonal  remains  of  the  Wolffian  bodies.  In  addition  to  these  theo- 
ries, the  possibility  of  dislocation  of  islands  of  epithelium  which  become 
embedded  in  the  subcutaneous  tissue,  the  result  of  trauma — as,  for 
•example,  childbirth,  or  operations  on  the  vagina,  which  afterward  give 
rise  to  cysts — must  always  be  borne  in  mind.  Finally,  dermoid  cysts 
may  develop  in  the  wall  of  the  vagina,  usually  in  the  recto-vaginal 
.septum. 

Cysts  of  the  vagina  are  rounded  tumours,  frequently  biscuit-shaped, 
hemispherical,  or  fusiform,  with  tense  elastic  walls  encroaching  on  the 
lumen  of  the  vagina.  Earely  they  may  assume  a  polypoid  shape,  having 
protruded  to  such  an 
•extent  as  to  form  a 
pedicle  (Fig.  80). 

The  cyst  wall 
varies  much  in  thick- 
ness. In  case  the 
■cyst  is  large  the  wall 
may  be  very  thin 
and  the  contained 
fluid  of  a  clear  col- 
our, giving  the  cyst 
a  bluish  translucent 
appearance. 

The  cyst  con- 
tents are  usually  a 
thin,  clear,  yellow- 
ish, transparent 
fluid,  though  they 
may  be  viscid,  tur- 
bid, and  even  of  a 
dark  -  brown  colour 
from  the  presence 
•of  disorganized 
blood.  Microscopic- 
ally, the  cyst  con- 
tents are  poor  in 
organized     elements,  ,      . ,    , 

,^       ,  •         11  ^i"^-  80  (Keed).— "  They  may  assume  a  polypoid  shape  hav- 

thOUgJl     occasionally  j^^^  protruded  to  such  an  extent  as  to  form  a  pedicle."- 

there  are  to  be  found  Rothrock. 

mucous       corpuscles 

and  groups  of  desquamated  epithelial  cells,  cylindrical  and  squamous, 

together  with  cholesterin  crystals  and  fatty  detritus.     Should  the  cyst 

become  infected  by  y)yogenic  micro-organisms,  suppuration  takes  place, 

and  the  contents  will  then  consist  largely  of  pus. 

Vaginal  cysts  are  usually  simple,  though  occasionally  the  remains 
of  septa  may  still  be  observed.     Earely,  multilocular  cysts  have  been 
•desci'ibed,  Poupinel  having  met  with  one  composed  of  fifteen  small 
16 


226  -^   TEXT-BOOK  OF   GYNECOLOGY 

cysts.  On  microscopic  examination  the  cyst  wall  is  made  up  largely  of 
fibrillary  connective  tissue,  though  in  a  certain  number  of  cysts,  smooth 
muscle  fibres  are  present,  more  or  less  uniformly  distributed.  Great 
difference  is  noted  in  the  epithelial  lining  of  vaginal  cysts.  Usually 
it  consists  of  a  single  layer  of  columnar  epithelial  cells,  which  may  be 
ciliated.  Occasionally  the  epithelial  lining  is  polymorphous,  consisting 
of  cuboidal,  cylindrical,  and  squamous  cells,  or  the  cylindrical  cells  may 
be  entirel}'  replaced  by  the  squamous  type.  Veit  attributes  this  change, 
especially  when  the  cysts  are  large,  to  the  pressure  of  the  cyst  contents. 
In  a  few  instances  invaginations  of  the  epithelial  lining  into  the  cyst 
wall  have  been  observed,  the  occurrence  of  which  has  been  advanced  as. 
proof  of  the  glandular  origin  of  such  cysts. 

Fibroids  are  the  rarest  of  all  neoplasms  of  the  vagina.  They  are 
usually  rounded,  very  rarely  reaching  a  size  larger  than  an  orange,, 
tliough  tumours  weighing  as  much  as  two  pounds  have  been  observed. 
They  are  almost  invariably  solitary  and  usually  sessile,  only  exception- 
ally forming  a  pedicle.  Their  favourite  location  is  the  upper  portion  of 
the  anterior  vaginal  wall.  The  etiology  of  these  tumours  is  still  obscure. 
They  are  most  frequently  met  with  in  middle  life,  though  they  have 
been  observed  in  children.  Von  Eecklinghausen  has  advanced  the  the- 
ory that  these  tumours  are  in  reality  adenomyomata,  which  have  their 
origin  in  the  remains  of  the  Wolffian  ducts,  which  view,  however,  still 
lacks  confirmation. 

These  tumours  grow  from  the  fibrous  or  muscular  coat  of  the  vagina, 
and  are  usually  embedded  in  a  fibrous  capsule.  Their  histologic  struc- 
ture is  identical  with  that  of  fil:)roids  of  the  uterus,  consisting  largely  of 
connective-tissue  bundles  with  a  rather  sparse  intermixture  of  smooth 
muscle  fibres.  Striped  muscle  fibres  are  occasionally  to  be  seen,  in  which 
case  the  tumour  must  be  classed  as  sarcoma,  especially  when  occurring  in 
children.  The  mucous  membrane  covering  the  tumours  is  usually  in- 
tact, unless  destroyed  by  pressure,  when  they  will  present  ulcerated 
surfaces.  Fibroids  of  the  vagina  may  become  oedematous,  or  gangrenous 
and  sloughing,  and  may  be  cast  off  in  this  manner.  Polypi  are  simply 
fibroids  which  have  become  pedunculated.  They  do  not  differ  essen- 
tially in  structure  from  fibroids. 

The  treatment  of  benign  neoplasms  of  the  external  genital  organs 
represents  some  of  the  least  difficult  problems  in  surgery.  Varicose 
tumours  of  the  vulva,  when  they  exist  simply  as  enlargements  of  the 
veins  and  are  not  associated  with  extensive  hypertrophy  of  the  con- 
nective tissue,  should  be  treated  by  obliteration  of  the  veins.  This  to 
be  effective  must  be  done  thoroughly.  AVhen  the  varices  are  restricted 
to  the  vulva,  the  larger  trunks  of  the  veins  are  easily  detectable  and 
may  be  tied  by  subcutaneous  ligature.  The  ligatures  should  be  applied 
at  intervals  along  the  same  vessels,  and  the  vessels  themselves  should  be 
divided  between  the  ligatures.  The  same  principle  of  treatment  may  be 
applied  to  perivaginal  varices,  although  the  technique  is  rather  more 
difficult.     When  pudendal  varices  are  associated  with  extensive  hyper- 


,  NEOPLASMS  OF  THE   EXTERNAL   GENITAL   ORGANS  227 

trophy,  the  hypertrophied  area  may  be  excised.  In  many  of  these 
cases  the  varicose  condition  of  the  external  veins  is  but  an  index  of  the 
condition  of  all  the  veins  surrounding  the  vagina  and  extending  far  up 
into  the  pelvic  structures.  The  control  of  such  extensive  conditions 
is  very  difficult,  if  not  impossible.  Pibromyomata  and  cysts  of  either 
the  vulva  or  vagina  should  be  treated  by  extirpation. 

Malignant  Neoplasms 

Malignant  Neoplasms  of  the  Pudendum.^Malignant  tumours  of  the 
vulva  are  comparatively  rare.  If  we  remember  how  frequent  these  neo- 
plasms are  in  other  parts  of  the  female  genital  organs  this  must  excite 
our  comment.  Schwartz  collected  1,177  cases  of  carcinoma  of  the 
uterus  and  the  vulva.  Of  these,  only  30' cases  belonged  to  the  latter 
class;  the  rest  were  all  carcinomata  of  the  uterus.  We  are  not,  however, 
in  a  position  to  account  for  the  comparative  rarity  of  malignant  neo- 
plasms of  the  pudendal  organs. 

Carcinoma,  which  we  will  consider  first,  is  much  more  frequent  than 
sarcoma. 

Nothing  definite  is  known  as  to  any  predisposing  cause,  except  the 
advanced  age  of  the  patient.  Winckel,  who  has  seen  8,  and  collected 
from  the  literature  54,  cases,  found  that  6  cases  occurred  in  women 
under  forty  years:  16,  between  forty  and  fifty;  20,  between  fifty 
and  sixty;  and  20  cases  in  women  over  sixty  years.  It  can  not  be 
shown  that  simple  inflam.matory  processes  or  gonorrhoea  and  syphi- 
lis exert  any  predisposing  influence  with  reference  to  the  develop- 
ment of  carcinoma  of  the  vulva.  '  The  starting  points  for  these 
tumours  are  the  clitoris,  labia  majora  and  labia  minora,  the  perineum, 
and  rarely  the  glands  of  Bartholin.  In  the  case  of  the  latter  the  carci- 
noma has  a  glandular,  in  all  other  cases  a  squamous,  epithelial-celled 
type.  These  tumours  are  generally  characterized  by  an  extensive  new 
formation  of  tissue,  by  their  inclination  to  early  superficial  ulceration, 
hard  diffuse  infiltration  of  the  surrounding  tissues,  and  involvement  of 
the  neighbouring  lymph  glands,  particularly  those  in  the  inguinal  re- 
gion. The  glandular  involvement,  however,  in  some  cases  does  not 
seem  to  supervene  early. 

The  carcinomata  of  the  vulva,  from  certain  macroscopic  features, 
may  be  divided  into  several  groups,  which  are,  however,  not  distin- 
guished by  fine  microscopic  differences.  One  form  is  characterized  by 
a  prominent  tumour  formation.  The  affected  portion  of  the  vagina 
presents  a  roundish  tumor,  generally  of  moderate  size,  usually  not 
larger  than  a  hen's  Qgg  or  an  apple.  It  is  firm  and  hard  in  consistence, 
situated  in  the  upjior  layers  of  the  integument,  and  more  or  less  mov- 
able on  the  subcutaneous  tissues.  The  surface  is  formed  by  an  epi- 
dermis, which  has  a  tendency  to  form  warty  prominences  and  papillary 
excrescences.  If  these  tumours  are  seen  somewhat  later  they  are  not 
80  freely  movable  and  llieir  surface  has  become  ulcerated.     A  second 


228  A   TEXT-BOOK   OP  GYNECOLOGY 

form  takes  on  from  the  start  the  shape  of  a  diffuse  infiltration,  which 
does  not  project  materially  above  the  level  of  the  surrounding  skin.  On 
palpation  of  the  neoplasm  its  site  is  found  to  be  hard,  and  it  is  not  freely- 
movable,  but,  on  the  contrary,  is  firmly  fixed  to  its  surroundings.  This 
variety  likewise  soon  begins  to  ulcerate;  its  surface  either  shows  a  mass 
of  shallow,  uneven  granulations,  or  a  ragged  tissue  covered  with  a 
bloody,  dirty,  purulent  exudate.  The  third  form  from  the  beginning 
has  a  marked  tendency  to  ulceration,  and  presents  a  deep  craterlike 
ulcer  with  hard,  infiltrated^  overhanging  edges. 

Microscopically,  carcinoma  of  the  vulva  presents  a  typical  squamous 
epithelial-celled  cancer.  The  epithelia  of  the  stratum  germinativum 
proliferate  into  the  underlying  connective  tissue  in  the  form  of  pegs  or 
cylindrical  masses,  and  these  have  a  tendency  to  become  branched.  The 
proliferating  cells  speedily  undergo  cornification,  and  one  therefore 
finds  in  carcinoma  of  the  vulva  epithelial  pearls  or  "  onion  bodies  "  in 
great  number  and  very  typical  in  appearance.  The  younger  epithelia, 
which  have  not  undergone  cornification  and  have  preserved  a  columnar 
type,  together  with  the  somewhat  tubular  branched  character  of  the 
cell  nests,  may,  on  superficial  examination,  create  the  impression  of  a 
glandular,  tubular  carcinoma.  This  impression  is,  however,  erroneous, 
for  carcinomata  of  the  vulva  are  true  squamous-celled  neoplasms,  not 
glandular  carcinomata,  but  "  cancroids." 

When  after  removal  of  the  original  tumovir  a  recurrence  takes  place, 
the  latter  frequently  loses  the  characteristic  structure  of  a  cancroid, 
and  presents  a  tissue  composed  of  a  fibrillar  stroma  with  only  small 
epithelial  nests  in  which  epithelial  pearls  are  absent.  There  are  fre- 
quently found  in  the  neighbourhood  of  carcinoma  of  the  vulva,  near 
the  primary  tumour  or  near  recurring  metastasis,  whitish  patches  of 
epidermis,  which  condition  is  known  as  leucoplalcia.  These  spots 
microscopically  show  a  thickening  of  the  epidermis.  They  are  not 
characteristic  of  carcinoma  of  the  vulva,  since  they  are  also  found  in 
other  conditions. 

Carcinoma  of  the  vulvo-vaginal  glands,  of  which  a  few  cases  have 
been  reported,  forms  a  hard  tumour  situated  under  the  unchanged 
labium  majus.  Microscopic  examination  shows  an  alveolar  carcinoma 
with  remnants  of  normal  glandular  tissue  of  the  organ. 

Carcinoma  of  the  vulva  after  it  is  once  well  established  generally 
spreads  quite  rapidly  and  has  a  tendency  to  grow  around  the  urethra 
into  the  vaginal  walls,  into  the  pelvic  fascia,  and  into  the  perineum. 
Involvement  of  the  other  labium  majus  from  the  opposite  one  originally 
affected  has  likewise  been  several  times  observed.  The  prognosis  of 
carcinoma  of  the  vulva  appears  to  be  somewhat  better  than  that  of 
cancer  of  the  vagina,  but  recurrence  and  final  death  is  the  rule  even 
after  thorough  removal.  G-offe  has  reported  a  case  of  primary  epithe- 
lioma of  the  clitoris  followed  by  speedy  lymphatic  involvement.  A  sec- 
tion taken  from  a  case  of  Whitacre's  shows  a  typical  microscopic  picture 
of  epithelioma  of  the  clitoris  (Fig.  81). 


NEOPLASMS  OP   THE   EXTERNAL   GENITAL   ORGANS  229 

Sarcoma  of  the  vulva  is  very  rare.  The  number  of  cases  of  this  kind 
which  have  been  reported  is  very  small.  These  connective-tissue  neo- 
plasms are,  as  a  rule,  very  malignant,  and  there  are  few  well-authen- 
ticated cases  on  record  of  permanent  cure  after  the  removal  of  a  sar- 


FiG.  81. — "A  section  taken  from  a  case  of  Whitacre's  shows  a  typical  microscopic  picture 
of  epithelioma  of  the  clitoris."— Herzog  (page  228). 

coma  of  the  pudendal  organs.  The  sarcomata  of  this  region  usually 
present  themselves  as  large  spherical  tumours  arising  from  the  labia, 
the  clitoris,  or  the  region  of  the  external  meatus  of  the  urethra,  or  they 
may  first  be  observed  as  deeply  pigmented  warts  on  the  labia.  There 
have  been  described  round-  and  spindle-celled  sarcoma,  myxosarcoma, 
and  melanosarcoma.  The  latter  is  the  form  most  frequently  observed 
on  the  vulva.  Winckel,  among  ten  thousand  female  patients,  saw  only 
two  cases  of  sarcoma  of  the  vulva.  One  case  was  that  of  a  pregnant 
woman,  twenty-five  years  old,  with  a  tumour  the  size  of  a  man's  head, 
which  was  hanging  down  from  the  vulva,  suspended  on  a  pedicle  the 
size  of  a  child's  arm.  This  tumour  had  not  been  very  malignant,  since 
it  had  been  present  and  growing  for  eight  years.  Its  microscopic  ex- 
amination showed  it  to  be  a  round-celled  sarcoma.  Winckel's  second  case 
was  a  myxosarcoma.  Bruhn  operated  in  two  cases  of  fibrosarcoma,  and 
claims  that  he  obtained  a  permanent  cure.  Wernitz  reported  a  case  of 
spindle-celled  sarcoma.    Robb  has  described  a  myxosarcoma.     Ehren- 


230 


A   TEXT-BOOK  OF  GYNECOLOGY 


dorfer  has  seen  a  small  round-celled  sarcoma  springing  from  the  anterior 
part  of  the  meatus  urinarius  and  protruding  between  the  labia.  Older 
reports  have  been  furnished  by  G.  Simon  and  a  few  others.  There  have 
been  reported  altogether  about  a  dozen  cases  of  this  kind.  Somewhat 
more  numerous  are  the  reports  of  cases  of  melanosarcoma.  It  is  a  well- 
known  fact  that  the  vulva  is  freqiiently  the  seat  of  pigmented  spots  and 
pigmented  ngevi.  These  occasionally  become  the  starting  point  of  mela- 
notic sarcoma, 
which  is  generally 
of  a  most  malignant 
type.  Other  mela- 
nosarcomata  of  this 
region  do  not  begin 
in  superficial  pig- 
ment spots  or  nsBvi, 
but  in  the  deeper 
layers  of  the  mucous 
membrane.  They 
are  first  noticeable 
as  a  purplish  spot, 
which  spreads,  be- 
comes deeper  in  col- 
our, and  then  as- 
sumes the  shape  of 
a  simple  wart  or  of 
a  branched  papil- 
lomatous growth. 
ITaeckel  reported  a 
melanosarcoma  of  a 
deep  bluish  -  black 
colour  springing 
from  the  labia  mi- 
nora and  the  cli- 
toris. Miiller  de- 
scribed a  tumour  of 
this  kind  arising 
from  the  clitoris. 
Most  cases  reported 
took  their  origin 
from  the  labia  ma- 
Jora.  All  the  mela- 
nosarcomata  of  the 
vulva  observed  were 
characterized  by  a 
deep  pigmentation;  they  were  moderate  in  size.  As  a  rule,  they  soon 
reappeared  after  removal  and  speedily  led  to  the  formation  of  multiple 
metastases.    Sometimes  general  sarcomatosis,  cachexia,  and  death,  soon 


'-  .%,v 


Fig.  82. — "  Reeil  lia-^  k  mnved  a  trilobiilar  nielnnosarcoma  from 
the  meatus  urinariu=?  of  a  young  girl." — Herzog  (page  231). 


NEOPLASMS  OP  THE  EXTERNAL   GENITAL  ORGANS  231 


follow  operative  procedures.     Reed,  however,  has  removed  a  trilobular 

raelanosarcoma  from  the  meatus  urinarius  of  a  young  girl  with  complete 

success  (Fig.  83). 

Histologically,  these  new  growths  generally  are  composed  of  round 

cells;  occasionally  spindle  cells  are  found.     The  cells  contain  in  their 

protoplasm  a  great 

amount      of      a 

brownish  granular 

pigment,  which  is 

also     found     free 

between   the    cells 

composing     the 

tumour  (Fig.  83). 
Melano  -  carci- 

nomata     of     the 

vulva,    likewise 

very  malignant  in 
character,  have 
been  described. 
Dr.  Balfour  Mar- 
shall has  reported 

(Glasgow  Medical 
Journal)  the  case 
of  a  widow,  aged 
tifty-seven,  in 
whom  the  site  of 
the  clitoris  was 
occupied     by     a 

dark-bluish  and  bluish-red,  slightly  lobulated  tumour,  of  the  size  of  a 
small  walnut.  The  growth  was  removed  and  was  found  to  have  origi- 
nated in  the  clitoris  and  prseputium  clitoridis,  being  "  a  melanotic  sar- 
coma with  some  hemorrhage  into  its  substance."  Dr.  Marshall  was  able 
to  find  records  of  only  nineteen  cases  of  sarcoma  of  the  vulva,  of  which 
two  started  in  the  clitoris. 

Malignant  tumours  primarily  situated  elsewhere  in  the  body  not 
infrequently  form  metastases  in  the  vulva.  Carcinomata  and  sarcomata 
of  the  uterus  lead  to  metastases  in  the  pudendal  organs,  as  also,  at  times, 
do  malignant  neoplasms  of  the  ovaries  and  of  the  urinary  bladder. 
Syncytioma  malignum  of  the  uterus,  which  so  frequently  forms  metas- 
tases in  the  vagina,  is  also  liable  to  form  metastatic  tumour  masses  in 
the  vulva.  Aschoff  reports  a  case  of  syncytioma  where  the  original 
tumour  has  made  a  metastasis  in  the  left  labium  majus. 

Malignant  Neoplasms  of  the  Vagina. — (a)  Sarcoma  in  Childhood. — 
Primary  sarcoma  of  the  vagina  occurs  at  any  period,  in  infancy  as  well  as 
in  adult  life,  and,  since  there  is  a  very  great  difference  in  its  appear- 
ance and  mode  of  development  in  the  two  ages,  allowing  a  sharp  subdivi- 
sion, it  is  customary  among  writers  to  treat  these  subdivisions  separately. 


Fig.  83  (Eeed). — "  A  brownish  granular  pigment,  which  is  found 
free  between  the  cells  composing  the  tumour." — Hebzog. 


232  A  TEXT-BOOK  OF   GYNECOLOGY 

In  children,  as  in  adults,  it  is  a  rare  disease,  and  usually  manifests 
itself  during  the  first  two  or  three  years  of  life.  Granicher  observed 
a  case  in  a  newborn  child,  which,  however,  advanced  very  slowly  and 
did  not  prove  fatal  until  the  seventh  year  of  life. 

Sarcoma  in  children  commonly  appears  in  the  form  of  polypoid  or 
grapelike  protrusions,  usually  springing  from  the  anterior  wall  of  the 
vagina.  In  the  beginning,  the  tumour  is  rounded  or  hemispherical 
with  a  broad  base,  but  it  tends  to  become  polypoid  as  the  disease  ad- 
vances. It  is  generally  of  a  cherry-red  colour,  but  it  may  be  dark  brown 
if  very  vascular.  Soon  the  surrounding  mucous  membrane  becomes 
infiltrated  and  here  and  there  in  the  surrounding  structure  secondary 
nodules  begin  to  develop.  Sarcoma  shows  a  marked  tendency  to  infil- 
trate the  vesico-vaginal  septum  and  invade  the  bladder,  and  may,  from 
pressure  on  the  urethra,  or  infiltration  of  the  neck  of  the  bladder,  cause 
urinary  stasis  with  resulting  dilatation  of  the  bladder  and  nephydro- 
sis.  In  advanced  cases  the  tumour  is  very  prone  to  undergo  ulceration 
or  necrosis  with  resulting  infection  of  the  genito-urinary  tract,  which 
ultimatel}'  reaches  the  kidneys,  terminating  in  pyelonephritis.  Earely,, 
the  infection  may  extend  to  the  uterus,  and  even  to  the  peritoneal 
cavity.    The  recto-vaginal  septum  may  also  be  involved. 

Metastasis  to  distant  parts  of  the  body  has  not  been  observed, 
though  regional  metastasis  to  the  inguinal  glands  and  ovary  has  been 
met  with. 

Histologically,  the  tumour  may  consist  largely  of  connective  tissue,. 
or  it  may  assume  the  type  of  myxosarcoma.  The  sarcomatous  ele- 
ment may  consist  of  round  or  spindle  cells,  or  both  may  be  present. 
Occasionally  giant  cells  are  observed,  and  not  infrequently  striped 
muscle  fibres  are  to  be  seen.  According  to  Kolisko,  striped  muscle 
fibres  are  usually  present,  but  other  observers  have  failed  to  confirm 
this  view. 

The  etiology  is  unknown.  However,  since  it  begins  in  infant  life, 
Veit  (HandbooJc,  p.  355)  regards  it  as  probable  that  in  some  cases  at 
least  it  is  congenital.  Kolisko  also  regards  the  presence  of  striped 
muscle  fibre  as  evidence  of  congenital  origin. 

(h)  Sarcoma  in  Adiilfs. — Primary  sarcoma  of  the  vagina  occur- 
ring in  adults  belongs  to  the  rarer  tumours.  Up  to  the  present  time 
but  thirty-one  cases  have  been  reported.  They  have  been  observed  be- 
tween the  ages  of  fifteen  and  eighty-two,  though  the  larger  proportion 
has  occurred  in  persons  under  forty  years  of  age.  They  most  frequently 
grow  from  the  anterior  wall  and  are  rather  more  frequent  in  the  lower 
third  of  the  vagina.  They  appear  as  more  or  less  circumscribed 
tumours,  which  is  the  most  common  form,  less  frequently  as  a  diffuse 
infiltration  of  the  mucous  membrane  of  the  vagina,  which  tends  to 
ulceration.  In  the  circumscribed  form  the  tumour  is  usually  smooth, 
rounded  or  hemispherical  in  shape,  and  sometimes  is  encapsulated. 
The  integrity  of  the  mucous  membrane  covering  the  tumour  is  usually 
maintained  until  pressure  from  its  increasing  size  produces  ulceration. 


NEOPLASMS   OF   THE  EXTERNAL   GENITAL   ORGANS         233 

Metastases  to  distant  parts  of  the  body  have  been  observed,  notaljly  to 
the  lungs  and  skin. 

Of  the  etiology  of  these  tumours  we  know  as  little  as  of  sarcoma 
in  general.  They  usually  have  their  origin  in  the  perivaginal  connective 
tissue,  or  in  the  submucosa.  Occasionally  they  originate  in  the  blood 
or  lymph  vessels,  when  they  are  termed  endothelioma.  Cases  of  this 
kind  have  been  reported  by  Klein,  Kalustow,  and  Waldstein. 

Histologically,  sarcoma  of  the  vagina  in  the  adult  may  consist  of 
spindle,  round,  or  mixed  cells,  and  occasionally  giant  cells  are  present. 
Sarcoma  of  the  vagina  is  especially  characterized  by  the  tendency  to 
recurrence  after  removal,  and,  according  to  Jung  {Monatsschrift  fiir 
Gehurtshillfe  und  Gynakologie,  Bd.  ix),  only  three  cases  are  on  record 
which  have  passed  without  recurrence  a  sufficient  length  of  time  after 
removal  to  be  denominated  cured. 

The  vagina  may  be  secondarily  involved  by  sarcoma,  which  pri- 
marily has  its  seat  in  some  other  region  of  the  body,  as,  for  example, 
the  uterus.  Especially  is  this  so  in  sarcoma  of  the  cervix,  where  sec- 
ondary involvement  of  the  vagina  is  almost  the  rule. 

(c)  Carcinoma. — Primary  carcinoma  of  the  vagina  is  not  common. 
Gurlt,  among  59,600  patients,  found  114  cases.  Unlike  sarcoma,  it  is 
a  disease  of  later  life,  and  has  not  been  met  with  under  the  age  of 
twenty-five.  It  appears  mostly  as  an  ulcerating  excrescence,  with 
sharply  circumscribed  borders,  and  is  most  frequently  located  on  the 
upper  portion  of  the  posterior  vaginal  wall.  The  surrounding  mucous 
membrane  is  usually  involved  in  a  catarrhal  inflammation,  and  is  fre- 
quently eroded  and  bleeds  on  the  slightest  touch.  ISTot  infrequently 
a  marked  thickening  of  the  mucous  membrane  in  the  neighbourhood 
of  the  carcinomatous  involvement  appears  as  a  diffuse  infiltration, 
manifested  as  a  thickening  of  the  vaginal  walls  encroaching  upon  the 
lumen  of  the  vagina.  At  first  it  may  involve  only  a  segment  of  the 
vagina,  encircling  its  entire  circumference  like  a  band.  In  these  cases 
ulceration  is  only  observed  after  a  considerable  length  of  time.  In  the 
diffuse  variety  the  growth  is  at  first  slow,  but  eventually  infiltration 
of  the  perivaginal  connective  tissue  takes  place  and  the  growth  may 
invade  the  bladder  or  rectum,  or  extend  into  the  parametrium,  involv- 
ing secondarily  the  iliac  and  retroperitoneal  glands,  or,  in  case  the 
growth  is  confined  to  the  lower  third  of  the  vagina,  the  inguinal  glands 
may  become  involved. 

The  etiology  is  obscure.  In  a  few  instances  it  has  been  observed 
to  develop  at  the  point  of  pressure  from  pessaries,  especially  where 
their  long-continued  use  has  caused  ulceration.  These  cases  have 
many  points  in  common  with  carcinoma  of  the  skin,  which  some- 
times develops  in  the  border  of  indolent  ulcers.  In  the  present  state 
of  our  knowledge  concerning  the  etiology  of  carcinoma,  it  is  difficult 
to  say  just  what  influence  the  pessary  has  had  as  an  exciting  cause 
of  the  carcinoma,  and  whetlier  the  irritation  following  its  use,  or  tlie 
ulceration    by    jorodiicing   an   atrium   of   infection,    has   been   chiefly 


234 


A  TEXT-BOOK  OP  GYNECOLOG-Y 


instrumental  we  do  not  know.  Microscopically,  primary  carcinoma  of 
the  vagina  presents  the  characteristics  of  carcinoma  growing  from  the 
skin  and  consists  of  squamous  epithelial  cells. 

Secondary  Carcinoma. — Secondary  carcinoma  of  the  vagina  is  of 
much  more  frequent  occurrence,  and  may  result  from  direct  exten- 
sion or  metastasis.  Most  frequently  it  is  secondary  to  carcinoma 
of  the  uterus,  especially  to  involvement  of  the  portio  vaginalis.  In 
carcinoma  of  the  body  of  the  uterus  the  vagina  may  be  secondarily 
involved  by  implantation  metastasis.  Carcinoma  of  the  rectum  or 
bladder  may  secondarily  invade  the  vagina,  and  occasionally  metas- 
tasis to  the  vagina  has  been  observed  to  follow  primary  carcinoma 
of  the  ovary.  Secondary  carcinoma  of  the  vagina  partakes  of  the 
nature  of  the  primary  growth  and  is  identical  in  its  histologic 
structure. 

Treatment  of  malignant  neoplasms  of  the  external  organs  of  gen- 
eration resolves  itself  into  radical  and  palliative.  The  radical  treatment 
consists  in  the  extirpation  of  the  malignant  growth  whenever  it  is  so 
situated  that  its  removal  can  be  accomplished  with  reasonable  safety 
to  the  life  of  the  patient  and  with  a  reasonable  prospect  of  complete- 
ness. Malignant  tumours  of  the  vulvo-vaginal  glands,  those  involving 
either  labium,  the  vagina,  or  the  clitoris,  should  be  freely  excised,  care 

being  taken  to  dissect  out  all 
indurated  neighbouring  lym- 
phatics. 

Clitoridectomy,  or  excision 
of  the  clitoris,  may  be  de- 
manded for  the  cure  of  either 
malignant  or  tuberculous  dis- 
ease of  that  body;  also  for  the 
removal  of  a  malformed  or  hy- 
pertrophied  clitoris,  or  for  the 
relief  of  extreme  nervous  dis- 
turbances due  to  hyperes- 
thesia of  that  organ.  The 
technique  of  the  operation  is 
as  follows:  Divide  the  tissues 
around  the  base  of  the  gland 
by  means  of  scissors,  one  blade 
of  which  is  inserted  beneath 
the  integument,  at  the  inner 
duplication  of  the  preputial 
fold,  and  is  carried  entirely 
round  the  organ;  the  prepuce 
is  then  slit  toward  the  pubis  (Fig.  84);  the  clitoris  is  dissected  out,  but, 
before  being  excised,  its  base  is  clamped  by  a  slender-bladed  Kocher 
hemostatic  forceps  (Fig.  85);  after  which  it  is  cut  away,  the  vessels 
being  controlled  by  ligatures.     The  flaps  are  approximated  by  buried 


Fig.  84. — "  The  prepuce  is  then  slit  toward  the 
pubis." — Keed. 


NEOPLASMS  OP  THE  EXTERNAL  GENITAL  ORGANS 


235 


animal  sutures  and  the  margins  of  the  wound  are  closed  by  the  inter- 
cutaneous  method.     (See  Figs.  38,  39.) 

Extirpation  of  the  vagina  is  sometimes  practised  in  cases  of  primary 
carcinoma  or  of  tuberculosis  of  that  canal.  Very  satisfactory  reports  of 
the  operation  have  been  made  by  Olshausen,  Diihrssen,  Martin  (of 
Greifswald),  and  others.  In 
the  performance  of  this  oper- 
ation it  may  be  necessary,  as 
a  preliminary  step,  in  cases 
of  narrow  or  indurated  va- 
ginae, to  incise  the  perineum, 
or  even  to  carry  the  incision 
entirely  through  the  peri- 
neum, round  the  anus,  and 
up  to  the  coccyx.  As  a  rule, 
however,  the  operation  may 
be  done,  as  Martin  directs,  by 
making  a  preliminary  inci- 
sion round  the  hymenal  ring 
at  the  introitus  vaginae.  Af- 
ter this  has  been  done,  but 
little  difficulty  is  experienced 
in  enucleating  the  vagina  by 
means  of  the  finger,  separat- 
ing the  entire  canal  from  its 
underlying  connective  tissue 
clear  to  its  Juncture  with  the 
cervix.    If  the  disease  has  not 

gone  beneath  the  mucous  membrane,  the  resulting  disturbance  of  the 
blood  vessels  will  not  be  so  marked  as  to  occasion  serious  difficulty  in 
controlling  the  hemorrhage.  If,  however,  the  incision  must  be  made 
through  the  perineum,  round  the  rectum,  and  up  to  the  coccyx,  the 
hemorrhage  from  the  hemorrhoidal  plexus  may  be  controlled  only 
with  some  difficulty.  After  the  vagina  has  been  enucleated  in  the 
manner  indicated,  the  remainder  of  the  operation  consists  in  the  re- 
moval of  the  uterus  and  adnexa  according  to  the  technique  described 
in  Vaginal  Hysterectomy.  The  proposition  has  been  made  by  P.  Miiller 
to  extirpate  the  vagina,  leaving  the  senile  uterus  in  situ;  but  as  even 
the  senile  uterus  is  the  source  of  some  secretion  which  will  accumulate 
above  the  tract  of  the  vagina,  which  now  becomes  occluded,  it  is  essen- 
tial that  even  in  these  cases  the  uterus  should  be  removed.  Partial 
extirpation  of  the  vagina  has  been  practised  by  Fritsch  and  Asch,  but 
the  results  have  not  been  satisfactory.  The  method  of  Martin,  as 
before  described,  is  probal)ly  the  safer,  the  operation  being  concluded 
l)y  drawing  down  the  peritoneum  and  stitching  it  all  round  at  the 
introitus.  After  this  step  has  been  taken  the  vulvar  orifice  closes  itself 
l)y  transverse  obliteration. 


Fig.  85.—"  The  clitoris  is  dissected  out,  but  before 
being  excised  its  base  is  clamped." — Reed  (p.  234). 


236  ^   TEXT-BOOK  OF  GYNECOLOGY 

The  palliative  treatment  of  malignant  neoplasms  of  the  external 
genital  organs  consists  in  making  the  patient  as  comfortable  as  pos- 
sible during  the  persistence  of  the  disease,  and  should  be  adopted  as  a 
line  of  practice  only  in  cases  that  are  either  awaiting  operation,  or  that 
have  ceased  to  be  suited  to  it  in  consequence  of  the  extension  of  the 
disease.  Of  the  latter  class  may  be  mentioned  as  examples  car- 
cinoma of  the  vagina  invading  and  penetrating  the  recto-vaginal  sep- 
tum, thereby  causing  a  recto-vaginal  fistula,  or  other  cases,  again,  in 
which  the  disease  has  perforated  the  bladder.  These  are  distinctly 
hopeless  conditions,  entirely  beyond  the  reach  of  surgical  art,  their 
comfort,  or  the  little  that  may  be  secured  for  them,  depending  on  vari- 
ous palliative  measures.  Cleanliness  is  of  the  first  consideration; 
douches  of  lysol  or  creolin  are  cleansing,  antiseptic,  and  are  better 
borne  than  the  more  irritating  solutions  of  either  carbolic  acid  or  the 
mercuric  bichloride.  Excoriated  surfaces  may  be  dressed  with  steril- 
ized white  vaseline  or  other  oleaginous  product,  a  little  lysol  or  creolin 
being  incorporated  with  this  agent  if  desired.  Opiates  in  the  form  of 
rectal  suppositories,  or  hypodermic  injections  of  morphine,  should  be 
given  whenever  they  are  not  contraindicated  by  the  idiosyncrasy  of  the 
patient.    These  are  cases  for  euthanasia. 


CHAPTER    XX 


DISPLACEMENTS   OF   THE   VAGINA 


The  vagina — Varieties  of  displacements — Cystocele — Rectocele — Urethrocele — Col- 
porrhaphy,  anterior  and  posterior. 

The  vagina  is  a  canal  lined  with  a  mucous  membrane  partaking 
largely  of  the  histologic  elements  of  the  integument,  and  is  surrounded 
by  some  muscular  stria3  that  are  designated  as  the  sphincter  vaginae 
muscle.      The  tube  thus  constituted  extends  from  the  vulva  to  the 

uterus  and  is  sur- 
rounded by  more  or 
less  loose  cellular  tis- 
sue. It  is  slightly 
curved,  being  concave 
anteriorly  and  convex 
posteriorly.  It  is  held 
in  position,  not  alone 
by  its  attachment  to 
its  surrounding  cellu- 
lar tissue,  but  more 
particularly  by  its  at- 
tachment to  the 
uterus  and  the  pelvic 
diaphragm,  and  by  the 
support  which  it  de- 
rives from  the  perine- 
um. This  canal  is 
liable,  in  whole  or  in 
part,  to  displacement. 
Upward  displacement 
may  occur,  as  in  the 
case  of  a  large  fibroid 
tumour,  the  growth  of 
which  carries  it  above 
the  pelvic  brim,  caus- 
ing it  to  drag  the  vagina  upward.  This  upward  displacement  may  occur 
to  such  a  degree  as  to  exercise  more  or  less  tension,  even  upon  the  lower 
segment  of  the  canal.  Downward  displacement,  or  a  prolapse  of  the 
vagina  or  some  part  of  it,  is  the  condition  more  frequently  encoun- 

237 


Fig.  86. — "Sacculations  may  occur  from  the  urethra,  a  con- 
dition called  urethrocele." — Eeed  (page  238). 


238 


A  TEXT-BOOK  OP   GYNECOLOGY 


tered.  The  causes  of  prolapse  of  the  vagina,  or  of  one  or  the  other 
or  both  of  its  walls,  may  exist  either  in  the  pelvic  diaphragm  or  in 
the  pelvic  floor.  Weakness  of  the  pelvic  diaphragm — a  condition  which 
depends  upon  the  loss  of  the  retentive  power  of  the  pelvic  fascia — is 
generally  manifested  primarily  by  descensus  uteri.  When  this  condi- 
tion occurs  it  is  always  and  necessarily  associated  with  more  or  less 
descent  of,  at  least,  the  upper  segment  of  the  vagina.  This  is  gen- 
erally specially  marked  in  relaxation  and  descent  of  the  floor  of 
Douglas's  pouch.  Occasionally  this  condition  of  the  pelvic  diaphragm, 
with  its  associated  hysteroptosis,  is  sufficient  to  cause  more  or  less 
descent  of  the  anterior  vaginal  Avail.  Eelaxation  of  the  pelvic  floor 
or  the  enlargement  of  the  vaginal  orifice  by  laceration  of  the  perineum 
may,  by  removing  the  support  from  the  superimposed  structures,  in- 
duce a  similar  prolapse  of  the  vaginal  wall.  When  the  anterior  vagi- 
nal wall  folds  inward  it  forms  a  sort  of  pouch  from  the  bladder  and 
is,  therefore,  designated  a  cystocele ;   when  the  posterior  wall  folds  into 

the  vagina  and  forms 
a  pouch  from  the  rec- 
tum, the  condition  is 
designated  a  rectocele 
(Figs.  86,  87).  Simi- 
lar sacculations  may 
occur  from  the  ure- 
thra —  a  condition 
called  urethrocele 
(Fig.  86). 

The  pathology  of 
these  displacements, 
particularly  of  cysto- 
cele and  rectocele, 
shows  them  as  con- 
sisting essentially  in 
an  atrophy  of  the 
perivaginal  rnuscu- 
laris,  with  a  corre- 
sponding loss  of  its 
retentive  power;  and 
in  a  distention  with 
resulting  redundancy 
of  the  vaginal  mu- 
cosa. The  symptoms 
of  these  sacculations 
are  very  characteris- 
tic. In  cystocele  the  patient  is  conscious  of  more  or  less  distention  of  the 
vaginal  orifice  when  she  attempts  to  urinate;  she  experiences  difficulty 
in  completely  emptying  the  bladder,  often  being  forced  to  push  that 
viscus  upward  with  the  finger  before  being  able  to  empty  it.     When 


Fig.  87. — "  There  is  always  more  or  less  residual  urim-  remain- 
ing in  the  adventitious  pouch." — Eeed  (page  239). 


DISPLACEMENTS  OF   THE   VAGINA 


239 


this  sacculation  is  extreme  she  may  be  unable  to  completely  empty 
the  bladder,  even  though  she  assists  herself  by  the  means  indicated; 
under  these  circumstances  there  is  always  more  or  less  residual  urine 
remaining  in  the  adventitious  pouch  (Fig.  87) — a  condition  which 
sooner  or  later  results 
in  inflammation  of 
the  bladder,  with  the 
usual  pain  and  tenes- 
mus. On  inspection, 
a  globular  mass,  which 
can  be  readily  re- 
placed by  the  finger 
and  which  increases 
in  size  and  tension  if 
the  patient  strains, 
will  be  seen  present- 
ing at  the  vulvar  ori- 
fice. A  curved  sound, 
introduced  through 
the  urethra  into  the 
bladder,  can  be  readily 
felt  on  the  inside  of 
this  pouch,  thus  ren- 
dering certain  the  di- 
agnosis of  cystocele. 
In  rectocele  the  pa- 
tient when  straining 
at  stool  feels  as  if  she 
were  about  to  defecate 
through  the  vagina, 
and  finds  it  necessary 
sometimes  to  replace 
the  protruding  mass 
before  she  can  empty 
the  rectum.  If  the 
finger  is  introduced 
into  the  rectum  in 
such  a  case  as  this  it 
can  be  brought  for- 
ward into  the  pro- 
truding pouch,  which 

presents  at  the  vulvar  orifice  as  a  globular  mass,  having  the  colour 
of  the  vagina  and  presenting  the  half-obliterated  rugge  upon  its  sur- 
face. If  the  patient  strains  or  coughs  the  protruding  mass  increases 
in  both  size  and  tension. 

The  treatment  of  displacements  of  the  vagina  consists  primarily  in 
correcting,  so  far  as  possible,  the  causative  conditions.     When  these 


Fig.  88.—".  .  .  Transverse  denmhitinns,  so  tliat  the  resulting 
line  of  approximation  may  be  coincident  with  the  normal 
folds  of  the  vagina."— Keed  (page  242). 


240 


A  TEXT-BOOK  OF  GYNECOLOGY 


exist  in  the  pelvic  diaphragm,  as  when  they  depend  upon  prolapse 
of  the  uterus,  the  remedy  is  to  be  found  in  relieving  the  vagina  of 
the  abnormal  pressure.  This  is  generally  accomplished  by  one  or 
other  of  the  recognised  operations  for  the  cure  of  prolapsus  uteri. 
(See  Surgical  Treatment  of  Uterine  Displacements.)  Pessaries  are, 
as  a  rule,  more  mischievous  than  otherwise;  although  their  use  may 

afford  the  patient  a 
sense  of  temporary 
comfort.  Those  pes- 
saries, however, 
which  by  their  con- 
struction distend  the 
vagina,  or  impinge 
forcibly  upon  any 
part  of  its  walls, 
have  a  tendency  to 
dilate  the  canal  still 
further  and  render 
the  original  mischief 
more  troublesome.  In 
the  place  of  pessaries 
it  is  usually  better  to 
employ  tamponade 
with  some  astrin- 
gent and  antiseptic 
medicament.  In 
cases  of  extreme  rec- 
tocele  or  cystocele, 
or  both,  either  com- 
bined or  not  with 
complete  procidentia 
uteri,  temporary 
comfort  is  derived 
from  wearing  a  firm 
perineal  support. 
Protruding  vaginal 
surfaces  frequently 
become  excoriated, 
in  which  case  they 
t;,      „„    a  rn,  ,  ■       1  •  ,    1  •        should  be  treated  by 

±iG.  89. —    inere  are  cases,  however,  in  which  the  anterior  ^    i     i  •  j 

sacculation  of  the  recto-vaginal  septum  exists  without  ap-       Caretul  Cleansing  and. 
parent  injury  to  either  layer  of  the  pelvic  floor."— Eeed       emollient     applica- 

(page  242).  tions.    Such  mcthods 

of  treatment  are, 
however,  but  tentative,  cure  depending  upon  such  correction  of  the  un- 
derlying cause  and  acquired  morbid  changes  as  can  be  effected  only  by 
surgical  intervention.    If  the  condition  depends  upon  relaxation  or  en- 


DISPLACEMENTS  OF   THE   VAGINA 


241 


largement  of  the  vaginal  outlet,  the  latter  resulting  from  laceration  of 
the  perineiim  or  injury  to  the  pelvic  floor,  the  joroper  remedy  is  to  be 
found  in  a  restoration  of  the  perineum  or  pelvic  floor,  associated,  it  may 
be,  with  a  narrowing  of 
the  lower  segment  of  the 
vagina.  (See  Perineor- 
rhaphy.) This  may  need 
to  be  associated  with  the 
operation  for  either  eysto- 
cele  or  rectocele,  or  both. 
The  operation  for  cys- 
tocele  consists  in  narrow- 
ing the  anterior  wall  of 
the  vagina  and,  conse- 
quently, is  called  anterior 
colporrhaphy.  It  is  ac- 
complished, in  general 
terms,  by  removing  a  disk 
of  the  redundant  mucous 
membrane  from  tlie  pro- 
truding vaginal  wall,  and 
in  approximating  the 
margins  of  the  wound. 
The  disk  of  membrane 
thus  removed  may  be  el- 
liptical or  circular  in 
form,  and  may  vary  in 
dimensions  according  to 
the  size  of  the  cystocele. 
Fritsch  removes  a  circular 
piece  of  membrane,  from 
an  inch  to  an  inch  and  a 
half  in  diameter,  from 
the  most  prominent  part 
of  the  presenting  pouch; 
this  denudation  is  then 
encircled  by  a  single  tobacco-pouch  suture  which  is  drawn  up  and 
tied,  the  cystic  wall  being  pushed  upward  into  the  bladder  as  the 
suture  is  tightened.  The  technique  is  very  simple,  and  in  cases  of 
small  cystocele  the  operation  is  very  effective.  It  is  not  practicable, 
however,  in  very  large  protrusions,  in  which  there  is  marked  redim- 
dancy  of  tissue.  In  such  cases  it  is  better  to  remove  an  ellipse  of  tissue 
closing  the  wound  by  careful  linear  approximation  of  its  margins. 
Operators  differ  as  to  the  direction  that  should  be  given  to  the  long 
axis  of  this  elliptical  denudation.  They  formerly  made  the  long  axis 
of  tlie  denudation  coincident  with  the  long  axis  of  the  vagina; 
but  an  increasing  number  of  later  operators  prefer  to  make  one,  or 
17 


f^THUPKlNS 


Fig.  90.- 


-"  In  such  cases  the  vaginal  wall  should  be 
denuded." — Eeed  (page  242). 


242  A  TEXT-BOOK  OP  GYNECOLOGY 

perhaps  two,  transverse  denudations,  so  that  the  resulting  line  of 
approximation  may  be  coincident  with  the  normal  folds  of  the  vagina 
(Fig.  88).  Experience  seems  to  warrant  the  latter  innovation,  as 
there  is  less  tendency  to  retraction  and  the  results  seem  to  be  more 
permanent.  The  closure  can  be  effected  either  by  the  interrupted, 
or  the  buried  animal,  suture.  When  the  interrupted  suture  is  em- 
ployed it  should  be  removed  on  the  eighth  or  ninth  day.  (See  Opera- 
tive Treatment  of  Prolapsus  Uteri.) 

The  operation  for  redocele  consists  in  narrowing  the  posterior  wall 
of  the  vagina  and,  consequently,  is  called  posterior  colporrhaphy.  It 
differs  from  the  operation  on  the  anterior  wall,  chiefly  because  rectoeele 
as  a  rule  exists  as  a  complication  of  such  conditions  as  call  for  the 
repair  of  the  perineum  or  the  restoration  of  the  pelvic  floor.  The  re- 
dundancy of  tissue  is  reduced  by  removing  one  or  more  ellipses  trans- 
versel}^  from  the  vaginal  wall  and  approximating  the  edges  with  inter- 
rupted sutures.  (See  Perineorrhaphy,  Fig.  107).  There  are  cases,  how- 
ever, in  which  the  anterior  sacculation  of  the  recto-vaginal  septum 
exists  without  apparent  injury  to  either  layer  of  the  pelvic  floor  (Fig. 
89).  In  such  cases  the  vaginal  wall  should  be  denuded  as  indicated  in 
Fig.  90,  which  is  drawn  from  a  patient  in  whom  the  conditions  varied 
slightly  from  those  in  the  case  Just  mentioned.  The  mucous  margins  are 
then  approximated  by  interrupted  sutures,  beginning  first  with  one  tri- 
angle, then  with  the  other,  thus  forming  the  expanded  arms  of  a  Y. 
The  remaining  area  is  then  approximated  by  passing  the  interrupted 
sutures  from  side  to  side. 


CHAPTEE    XXI 
THE  VULVO- VAGINAL   GLAND 

Anatomy — Gonorrhceal  infection — Abscess — Cysts — Carcinoma. 

The  vulvo-vaginal  glands,  or  glands  of  Bartholin,  are  two  small 
rounded  or  oval  bodies  from  15  to  20  millimetres  in  length,  varying 
greatly  in  size  and  shape,  and  situated  in  the  posterior  third  of  the 
labia  majora,  one  on  either  side  of  the  lower  end  of  the  vagina, 
immediately  below  the  bulb  and  in  front  of  and  near  the  upper 
margin  of  the  perineal  septum 
(Fig.  91). 

They  are  racemose  glands 
the  acini  of  which  are  lined 
by  a  single  layer  of  high  co- 
lumnar epithelial  cells  with 
basal  nuclei.  They  secrete  a 
muco-serous  fluid  which  is 
emptied  through  two  slender 
ducts  of  about  2  centimetres  in 
length  and  terminating  in 
small  openings  in  the  vestibule 
about  1.5  centimetre  from  the 
posterior  median  line  just  out- 
side the  hymen.  These  ducts 
are  lined  by  low  cuboidal  epi- 
thelial cells  and  their  mouths 
are  plainly  visible  on  close  in- 
spection, being  of  sufficient 
size  to  admit  the  passage  of  a 
fine  probe.  Functionally,  the 
secretion  of  these  glands  serves 
to  moisten  the  mucous  mem- 
brane of  the  vestibule,  and  dur- 
ing sexual  excitation  or  coitus 

it  is  discharged  in  considerable  quantities.  These  glands  become  fully 
developed  at  the  age  of  puberty,  and  maintain  their  full  function  until 
the  climacteric,  when  they  begin  slowly  to  undergo  atrophy  and  their 
function  gradually  ceases.  The  location  of  the  mouths  of  these  ducts 
renders  them  peculiarly  liable  to  infection  which  may,  by  extension 

343 


Fig.  91. — "  The  vulvo-vaginal  glands  .  .  .  are 
situated  in  the  posterior  third  of  the  labia 
majora." — Kotheock. 


244  A   TEXT-BOOK  OF   GYNECOLOGY 

through  the  dnct^  involve  the  gland  and  result  in  a  series  of  inflamma- 
tor}'  conditions  constituting  the  chief  diseases  to  which  it  is  liable. 

Inflammation  must  be  regarded  as  invariably  due  to  bacterial  infec- 
tion, and  eases  apj^arently  the  result  of  trauma,  as  for  example  those 
following  on  childbirth,  are  now  generally  explained  by  the  pre- 
existence  of  pathogenic  bacteria  in  the  duct,  the  trauma  having  served 
merely  to  afford  an  atrium  of  infection.  While  various  bacterial  flora 
of  the  vulva  may  gain  entrance  to  these  ducts,  inflammation  is  almost 
invariably  of  gonorrhoeal  origin.  The  one  possible  exception  to  this 
is  the  staj)hylococcus,  which,  it  appears,  may  produce  inflammation 
either  alone  or  in  association  with  the  gonococcus.  All  other  bacteria, 
therefore,  which  may  at  times  be  present,  must  be  regarded  in  the 
light  of  secondary  invaders. 

Pure  gonorrhoeal  inflammation  usually  remains  confined  to  the 
ducts,  rarely  involving  the  parenchyma  of  the  gland,  and  then  only 
slightly. 

Gonorrhoeal  Infection  of  the  Ducts. — Infection  of  the  ducts  may 
occur  directly,  but  in  the  majority  of  cases  it  is  secondary  to  infection 
of  other  portions  of  the  genital  tract.  A  well-developed  case  of  gonor- 
rhoeal inflammation  of  the  vulvo-vaginal  gland  has  been  observed  four- 
teen days  after  exposure  to  infection  (Bumm),  but  this  is  exceptional, 
and  frequently  Aveeks  or  months  may  elapse  before  the  mouths  of  the 
ducts  become  infected  although  constantly  bathed  meanwhile  with 
vulvar  or  vaginal  secretions.  In  most  instances  both  ducts  are  in- 
volved, frequently  from  the  beginning,  but  almost  invariably  in  cases 
of  long  standing.  The  ducts  are  usually  involved  throughout  their 
entire  lengtli,  though  oftentimes  the  involvement  is  not  uniform 
throughout,  but  some  portions  of  the  duct  are  more  severely  attacked 
than  others. 

To  C.  Herbert  {Inaugural  Disse7iation,  Leipsic,  1893)  we  are  in- 
debted for  a  description  of  the  histological  changes  which  take  place 
in  gonorrhoeal  inflammation  of  the  gland  and  its  duct. 

They  consist  essentially  of  desquamation  of  the  epithelial  cells, 
with  a  small  round-celled  infiltration  of  the  intercellular  substance 
and  subepithelial  connective  tissue. 

At  first  the  epithelium  lining  the  duct  becomes  swollen,  and  even- 
tually loosened,  by  the  infiltration  of  leucocytes,  then  desquamation 
begins.  In  cases  of  long  standing,  the  desquamated  epithelial  cells  are 
replaced  by  cells  more  cuboidal  in  character,  often  approaching  the 
squamous  type.  The  lumen  of  the  duct  will  be  found  filled  with  pus 
and  desquamated  epithelial  cells  in  which  gonococci  may  be  demon- 
strated. The  gonococci  may  penetrate  to  the  subepithelial  connective 
tissue  but  are  not  found  in  the  infiltration  cells  themselves. 

Gonorrhoeal  inflammation  of  the  ducts  either  begins  as  a  chronic 
process,  or,  after  a  brief  and  ill-defined  acute  stage,  becomes  chronic. 
It  may  persist  for  months,  and  even  years,  an  ever-fruitful  source 
of  infection,  and,  indeed,  together  with  infection  of  Skene's  glands, 


THE  VULVO-VAGINAL   GLAND  245 

may  constitute  the  only  points  of  localization  of  the  infection  in 
women.  It  usually  occurs  some  time  during  sexually  active  life, 
though  Fischer  {Deutsche  meclicinische  Wcclienschrift,  1895)  has  observed 
it  in  children. 

Symptoms. — In  the  beginning,  gonorrhoea  of  the  ducts  gives  rise 
to  few  or  no  symptoms,  so  that  the  patient  may  be  totally  unconscious 
of  its  presence.  Occasionally,  there  is  a  sensation  of  itching  and  burn- 
ing and  perhaps  some  slight  sensitiveness  on  pressure,  or  the  patient 
may  complain  of  a  dull  pain  increased  on  walking  or  sitting. 

These  symptoms  when  they  occur  are  of  short  duration,  and  the 
patient  may  be  conscious  of  nothing  more  than  a  slight  muco-puru- 
lent  discharge.    Even  this  is  often  so  slight  as  to  escape  notice. 

On  examination,  if  the  labia  are  separated  so  as  to  bring  the  mouths 
of  the  ducts  into  view,  these  appear,  in  cases  of  recent  infection,  in 
the  form  of  dark-red,  glistening,  moist,  spots  resembling  small  ulcers, 
this  appearance  being  due  to  ectropion  of  the  inflamed  and  swollen 
mucous  membrane  lining  the  duct. 

If  pressure  is  made  along  the  course  of  the  duct,  a  thin  yellowish 
pus  may  be  made  to  exude  from  its  mouth,  often  in  considerable  quan- 
tities, which  examination  with  the  microscope  shows  to  consist  of  pus 
and  desquamated  epithelial  cells  in  which  gonococci  may  be  demon- 
strated in  large  numbers. 

Occasionally  a  nodular  swelling,  or  induration,  due  to  an  infiltra- 
tion of  the  subepithelial  connective  tissue  by  small  round  cells,  may 
be  felt  along  the  course  of  the  duct. 

When  the  disease  becomes  chronic,  similar  signs  may  be  observed 
though  less  pronounced.  The  secretion  now  becomes  more  mucoid 
in  character,  and  while  gonococci  may  still  be  demonstrated  they  are 
present  in  diminished  numbers. 

Frequently  the  only  remaining  sign  of  infection  is  the  appear- 
ance of  the  mouths  of  the  ducts,  which  Sanger  has  compared  with  flea- 
bites  and  has  named  "  maculae  gonorrhoeae,"  since  he  regards  them 
as  an  infallible  sign  of  gonorrhoea. 

Gonorrhoeal  inflammation  of  the  ducts  may  terminate  in  abscess  of 
the  glands  or  in  cyst  formation,  and  these  two  conditions  constitute 
the  chief  diseases  of  the  viilvo -vaginal  glands,  inasmuch  as  gonorrhoeal 
disease  of  the  ducts  is  so  devoid  of  symptoms  that  the  patient  is  seldom 
conscious  of  its  existence,  and  frequently  it  is  only  discovered  by  the 
examination  of  a  physician. 

Abscess. — Inflammation  of  the  parenchyma  is  invariably  due  to  in- 
fection by  pyogenic  bacteria,  most  frequently  the  Staphylococcus  pyo- 
genes aureus,  occasionally  the  Staphylococcus  pyogenes  alhus,  either  in 
association  with  the  gonococcus  or  alone,  and  in  a  few  instances  the 
Streptococcus  pyogenes  has  been  found  present  (Dujon).  In  addition 
to  these,  various  other  bacteria  are  sometimes  present  in  the  pus,  fre- 
quently the  Bacterium,  coli  commune;  and  in  one  case  of  relapsing 
abscess,  examined  by  Kothrock,  the  Bacillus  pyocyaneus  was  present. 


2i6  A   TEXT-BOOK  OF   GYNECOLOGY 

together  Avitli  the  Staphylococcus  pyogenes  aureus  and  other  undeter- 
mmed  bacilli. 

The  pus  has  frequently  a  foul  odour  similar  to  that  so  often  raet 
with  in  abscesses  occurring  about  the  anus,  and  in  all  probability  due 
to  the  associated  presence  of  the  colon  bacillus  or  putrefactive  bacteria. 

Inflammation  of  the  gland  is  almost  always  secondary  to  inflam- 
mation of  the  duct,  though  Eothrock  recalls  a  case  which  had  been 
under  observation  for  some  time,  in  which  there  was  no  evidence  of 
disease  of  the  ducts,  old  or  recent.  In  this  case  the  Staphylococcus 
pyogenes  aureus  was  found  in  pure  culture  and  no  gonococci  were 
demonstrable  in  the  ^dus. 

Abscess  of  the  gland  may  occur  at  any  stage  in  the  progress  of 
disease  in  the  duct,  and,  according  to  Bumm,  it  occurs  in  about  one 
third  of  all  cases  of  gonorrhoeal  infection  of  the  diict.  It  is  frequently 
met  with  in  prostitutes,  in  whom  gonorrhoeal  infection  is  unusually 
common.  In  this  class  of  patients  the  traumatism  incident  to  the 
abuse  of  coitus  seems  to  be  a  fruitful  exciting  cause. 

Not  infrequently  it  is  met  with  immediately  following  menstrua- 
tion in  the  absence  of  any  history  of  traumatism. 

Abscess  usually  develops  unilaterally  and  may  occur  on  either  side, 
appearing  to  have  no  predilection  for  one  side  over  the  other.  In 
case  the  disease  runs  a  very  acute  course,  the  parenchyma  of  the  gland 
is  quickly  destroyed,  and  the  infection  may  pass  through  the  mem- 
brana  propria  into  the  surrounding  cellular  tissue,  with  a  resulting 
phlegmon  which  terminates  in  suppuration  with  the  formation  of  an 
abscess.  Usually,  however,  the  inflammation  runs  a  less  acute  course 
and  remains  confined  to  the  capsule  of  the  gland,  which  quickly  be- 
comes distended  with  pus.  In  such  cases  the  cellular  tissue  outside 
the  gland  becomes  oedematous,  and  this  in  a  large  measure  accounts 
for  the  swelling  which  is  present. 

Symptoms. — Abscess  of  the  vulvo-vaginal  gland  as  a  rule  begins 
abrujjtl}',  and  manifests  itself  by  swelling  of  the  labia  majora  accom- 
panied by  the  usual  signs  of  acute  inflammation — redness,  heat,  and 
pain.  On  examination,  there  may  be  felt  in  the  posterior  third  of  the 
labia  majora,  and  often  extending  into  the  vagina,  an  irregular-shaped 
swelling  the  size  of  a  pigeon's  egg,  and  extremely  sensitive  on  pressure. 
After  a  few  days,  during  which  the  .symptoms  increase  in  severity,  the 
swelling  becomes  boggy  indicating  beginning  suppuration,  and  fluc- 
tuation may  soon  be  felt.  During  this  time  the  j)atient  will  usually 
find  locomotion  difficult  on  account  of  the  swelling.  The  pain  will 
have  increased  in  severity,  and  have  become  throbbing  in  character. 
In  severe  cases  there  is  usually  a  slight  elevation  of  temperature  reach- 
ing 101°  or  102°  F.,  and  the  onset  of  suppuration  may  be  ushered  in 
by  a  chill.  There  is  usually  some  swelling  of  the  inguinal  glands  on 
the  affected  side,  which  always  indicates  infection  by  pyogenic  bac- 
teria, as  it  is  never  present  in  pure  gonorrho?al  infection  (Sanger). 
With  the  accumulation  of  pus,  a  gradual  thinning  of  the  skin  and  sub- 


THE   VULVO-VAGINAL   GLAND  24T 

cutaneous  tissue  takes  place,  and  the  abscess,  if  not  opened,  points  and 
ruptures  spontaneously. 

Perforation  usually  takes  place  on  the  inner  surface  of  the  labia 
majora,  hut  the  pus  may  be  conducted  forward  between  the  layers  of 
the  ischiopubic  fascia,  and  point  in  the  fold  between  the  labia  majora 
and  labia  minora.  In  some  cases,  the  abscess  may  be  evacuated  through 
the  duct  by  pressure  made  in  that  direction;  but  this  is  exceptional,  as 
the  duct  is  usually  occluded,  or  at  least  does  not  communicate  with 
the  main  abscess  cavity.  Earely  the  pus  may  burrow,  and  the  abscess 
may  be  evacuated  through  the  perineum,  or  even  into  the  rectum  with 
resulting  fistulge.  The  pus  may  be  yellow,  dirty-green,  or  chocolate- 
coloured  from  altered  blood.  It  frequently  has  a  foul  odour,  and  may 
contain  gangrenous  shreds. 

Well-defined  abscesses  are  usually  sharply  limited  by  a  thick  pyo- 
genic membrane,  the  inner  surface  of  which  may  be  smooth,  or  irregu- 
lar from  necrotic  shreds,  or  from  trabeculae-like  septa  which  separate 
the  lobes  of  the  gland.  Inflammation  of  the  vulvo-vaginal  gland  almost 
invariably  terminates  in  sujDpuration,  though  occasionally  cases  are 
met  with  in  which  it  is  characterized  by  marked  induration  with  little 
tendency  to  the  accumulation  of  pus.  In  these  cases,  the  induration 
may  remain  for  a  long  time,  and  may  serve  as  a  focus  of  infection  for 
renewed  attacks  under  the  stimulus  of  traumatism. 

Cysts. — Cysts  of  the  vulvo-vaginal  gland  are  invariably  the  result 
of  occlusion  of  the  duct,  and  are  therefore  retention  cysts. 

The  vast  majority  are  secondary  to  gonorrhoeal  infection  of  the 
duct.  According  to  Sanger,  they  are  an  almost  certain  indication  of 
pre-existing  gonorrhoea,  while  Winter  maintains  that  they  may  result 
from  occlusion  of  the  duct  by  traumatism,  as,  for  example,  in  child- 
birth. 

Cysts  may  be  located  in  the  duct  or  in  the  gland.  Those  of  the 
duct  are  sm.all,  superficial,  and  may  remain  for  a  long  time  without 
the  patient's  knowledge,  being  only  discovered  accidentally  by  exami- 
nation. They  are  situated  in  the  lower  part  of  the  labia  majora  and 
at  first  are  fusiform,  but  later  they  tend  to  become  spherical.  Cysts 
of  the  gland  proper  are  larger,  and  are  more  deeply  situated.  From 
the  beginning,  they  are  spherical  in  shape,  and  may  develop  in  one 
lobule,  or  the  entire  gland  may  be  converted  into  a  cyst. 

The  wall  of  the  cyst  is  usually  thin  and  consists  of  connective  tis- 
sue, and,  occasionally,  the  remains  of  the  epithelial  lining  of  the  gland 
may  still  be  observed. 

The  cyst  contents  vary  in  character  ranging  from  a  thin  clear 
serous  fluid,  to  a  thick,  tenacious,  or  colloidlike,  accumulation,  vary- 
ing in  colour,  sometimes  clear  or  yellow,  and,  again,  brown  or  chocolate 
coloured  from  the  presence  of  altered  blood. 

Microscopically,  they  may  contain  blood  corpuscles,  leucocytes, 
epitbelial  cells,  cholestcrin  crystals,  and  detritus,  and  frequently  the 
presence  of  gonococci  may  be  dctnonstrated. 


248  ^  TEXT-BOOK  OF   GYNECOLOGY 

As  a  rule,  the  older  the  cyst,  the  clearer  will  be  its  contents.  In 
case  the  duct  is  not  altogether  occluded,  pressure  over  the  cyst  may 
force  out  some  of  its  contents,  and  occasionally  cysts  are  met  with 
which  empty  themselves  spontaneously  or  during  coitus,  and  which 
refill  again  after  a  time.  In  a  few  instances,  cysts  have  been  described 
which  contained  a  fatty  substance  similar  to  that  of  sebaceous  cysts. 
It  is  probable,  however,  that  these  were  cysts  which  had  their  origin 
in  the  sebaceous  glands  of  the  vulva. 

Occasionally,  cysts  are  met  with  which  contain  gonorrhoeal  pus,  the 
result  of  occlusion  of  the  duct.  Such  collections  have  been  termed 
pseudo-abscesses,  as  the  usual  signs  of  acute  inflammation,  such  as  are 
observed  in  staphylococcus  infection,  are  wanting,  except  perhaps  slight 
swelling  which  is  due  to  cedema. 

Cysts  of  the  vulvo-vaginal  glands  may  become  secondarily  infected 
by  pyogenic  bacteria,  following  on  which,  suppuration  ensues  and 
the  cyst  is  transformed  into  an  abscess,  with  the  usual  accompanying 
symptoms. 

Cysts  of  the  gland  proper  rarely  reach  a  size  as  large  as  a  hen's 
egg;  and  those  especially  large  ones  which  have  been  described,  the 
contents  of  which  were  clear  and  limpid,  were  probably  in  reality  vagi- 
nal cysts  from  the  remains  of  Gartner's  ducts. 

Treatment. — Gonorrhoea  of  the  ducts  usually  runs  a  very  chronic 
course  if  left  to  itself,  and,  owing  to  the  difficulty  of  access  of 
the  localized  points  of  infection,  often  proves  most  obstinate  to 
treatment. 

First  of  all,  cleanliness  of  the  external  genitals  should  be  secured 
by  antiseptic  douches.  The  duct  should  be  systematically  evacuated 
each  day  by  gentle  pressure  made  along  its  course  from  within  out- 
ward, after  which  an  application  of  an  8-per-cent  solution  of  nitrate 
of  silver  should  be  made  by  means  of  cotton  wrapped  on  a  slender 
probe.  Good  results  also  follow  the  use  of  a  2-per-cent  solution  of 
formalin  applied  in  the  same  manner.  "When  the  lumen  of  the  duct 
is  very  narrow  or  obliterated,  it  is  sometimes  best  to  lay  it  open  along 
its  entire  length,  and  this  is  most  conveniently  done  by  a  Weber's 
canaliculus  knife  such  as  is  employed  by  oculists  for  division  of  stric- 
ture of  the  lachrymal  duct. 

When  the  duct  has  been  laid  open  it  should  be  washed  out  with 
an  antiseptic  solution,  after  which,  either  of  the  above-mentioned 
solutions  of  silver  nitrate  or  formalin  may  be  applied. 

Pozzi  recommends  the  application  of  a  2-per-cent  solution  of 
chloride  of  zinc  or  cauterization  by  a  crayon  of  nitrate  of  silver,  while 
others  recommend  cauterization  with  pure  carbolic  acid. 

Inflammation  of  the  gland  is  to  be  treated  as  is  acute  inflammation 
elsewhere,  namely  by  rest  in  bed  and  by  cold  applications  until  sup- 
puration, as  is  the  almost  invariable  rule,  occurs,  when  the  abscess 
should  be  freely  opened,  washed  out  with  an  antiseptic  solution,  and 
packed  with  iodoform  gauze  to  encourage  granulation  from  the  bot- 


THE   VULVO-VAGINAL   GLAND  249 

torn.  As  a  rule  the  incision  should  be  made  over  the  most  superficial 
point,  which,  in  most  cases,  is  the  internal  surface  of  the  labium. 

Kelly  prefers,  however,  to  make  the  incision  over  the  skin  surface 
so  as  to  avoid  a  painful  cicatrix  which  sometimes  follows  an  incision 
made  over  the  mucous  surface. 

As  a  rule,  general  anaesthesia  will  not  be  necessary  for  the  opening 
of  these  abscesses,  but  local  anaesthesia  by  chloride  of  ethyl,  cocaine,  or 
the  application  of  ice,  will  be  quite  sufficient. 

Cysts  are  best  treated  by  extirpation,  after  which  the  opening 
should  be  immediately  closed  by  interrupted  sutures.  In  case  this  is 
not  possible,  after  thoroughly  laying  the  cyst  open,  an  attempt  should 
be  made  to  obliterate  its  cavity  by  cauterization  and  packing  with  iodo- 
form gauze.  Examination  should,  at  the  same  time,  be  made  of  the 
duet,  and,  if  found  diseased,  it  should  also  receive  attention;  otherwise 
it  may  remain  as  a  source  of  infection. 

Carcinoma. — One  other  disease  of  the  vulvo-vaginal  glands  deserves 
mention,  and  that  is  carcinoma.  While  of  rare  occurrence,  the  num- 
ber of  cases  which  have  been  reported  in  recent  years  renders  it  certain 
that  carcinoma  may  originate  in  the  epithelium  of  the  gland.  Clini- 
cally, it  appears  to  develop  in  middle  or  advanced  life,  as  a  rounded 
tumour  of  the  labium  which  does  not  tend  to  ulcerate.  Microscopically, 
the  tumour  frequently  follows  the  type  of  adeno-carcinoma.  Cases 
have  been  reported  by  Geist,  Martin,  Mackenrodt,  Wolf,  and  Kelly. 

The  treatment  here,  as  for  malignant  disease  in  other  regions  of 
the  body,  is  its  early  recognition  and  complete  removal. 

In  Martin's  case  the  patient  died  of  recurrence  four  years  after  the 
operation. 


CHAPTER    XXII 

THE   PELVIC   FLOOR  AND   ITS  INJURIES 

The  pelvic  floor — The  "pelvic  diaphragm" — Injuries  of  the  pelvic  floor — Lacera- 
tions of  the  perineum — Restorations  of  the  pelvic  floor — Immediate  operation 
— Instruments — Operations  for  incomplete  lacerations,  superficial — Emmet's 
operation,  Reed's  method  of  suture ;  modifications — Operations  for  complete 
lacerations;  Tait's  operation;  modifications — Repair  of  deep  injuries  of  the 
pelvic  floor — Harris's  operation. 


The  pelvic  floor  consists  of  those  structures  which  hy  their  muscu- 
hir  elements  are  attached  to  the  lowest  plane  of  the  pelvic  bones  and 
which  occupy  the  outlet  of  the  pelvis.     These  structures  considered  in 
their  entirety  include  integumentary,  aponeurotic,  and  muscular  ele- 
ments, and  are  penetrated  by  three  canals,  namely,  the  vagina,  the  ure- 
thra,   and    the    rec- 
tum.    The  function 
of    the    pelvic    floor 
is  to  serve  as  a  basis 
of    support    for    the 
superimposed        vis- 
cera.      This     power 
of    support    is    exer- 
cised   by    virtue    of 
the  aponeurotic,  and, 
particularly,     the 
muscular      elements 
of  the  floor;    and  it 
is  to  these  elements 
that    special    atten- 
tion is  invited.     The 
muscles   of   the   pel- 
vic    floor     are     ar- 
ranged in  two  layers, 
(a)  external,  and  (b) 
internal.    The  external  layer  of  muscles  embraces  the  bulbo-cavernosus, 
the  trans versus-peringei,  and  the  sphincter-ani-externus  muscle,  with 
fibres  from  the  pubo-coccygeus  and  the  obturator-coccygeus  muscles. 
These  muscles  meet  at  a  central  point  of  convergence,  which  may 
250 


Fig.  92. — "  These  muscles  meet  at  a  central  point  of  conver- 
gence, which  may  be  designated  the  nidus  perincei.'''' — 
Eeed  (page  251). 


THE   PELVIC   FLOOR  AND  ITS  INJURIES 


251 


Fig.  93. — "  The  internal  layer,  as  described  by  M.  L.  Harris, 
is  composed  of  four  paired  muscles." — Eeed. 


with  propriety  be  designated  the  nidus  perincei  (Fig.  92).  Tlie 
perineum  proper  is  a  pyramidal  structure  the  base  of  which  lies 
between  the  fourchette  and  the  anus,  while  its  apex  blends  with  the 
recto-vaginal  septum;  its  essential  structures  are  derived  from,  and 
constitute  a  part  of,  the  external  muscular  layer  of  the  pelvic  floor. 
The  internal  muscular 

layer    of    the     pelvic      ^  ■■"■  "  '     ^ 

floor  occupies  a  plane 
about  1.5  centimetre 
above  the  external 
layer,  and,  as  de- 
scribed by  M.  L.  Har- 
ris (Journal  of  the 
American  Medical  As- 
sociation), is  composed 
of  four  paired  muscles 
(Fig.  93). 

Harris  says  that 
"  it  is  not  always  easy 
in  a  human  subject  to 
draw  sharp  lines  of 
demarcation  between 
some  of  these  muscles 
at     all     points,     and 

some  knowledge  of  comj)arative  anatomy  is  necessary  to  a  clear  un- 
derstanding of  them.  Comparative  anatomy  teaches  us  that  these 
muscles  are  the  representatives  of  well-developed,  clearly  defined  mus- 
cles, which,  in  the  lower  animals  are  concerned  in  the  movements  of 
the  caudal  appendage,  and  which,  owing  to  the  loss  of  the  caudal  appen- 
dage and  the  assumption  of  the  erect  posture  through  evolution,  have 
somewhat  readjusted  their  character  and  attachments,  to  conform  to 
their  new  function  of  closing  the  pelvic  outlet  and  supporting  the  pel- 
vic contents.  These  four  muscles  are  called  the  ischio-coccygeus,  the 
ilio-coccygeus,  the  pubo-coccygeiis  and  the  pubo-rectalis.  The  ischio- 
coccygeus  which  arises  from  the  spine  of  the  ischium  and  is  inserted  into 
the  lateral  border  of  the  lower  part  of  the  sacrum  and  the  upper  part  of 
the  coccyx;  and  the  ilio-coccygeus,  which  arises  from  the  iliac  portion 
of  the  obturator  fascia  and  in  inserted  into  the  lateral  border  of  the 
lower  part  of  the  coccyx,  have  comparatively  little  remaining  physio- 
logical importance  or  surgical  significance." 

The  remaining  two  muscles,  however,  are  of  extreme  importance. 
"  Tlio  pvibo-coccygeus  arises  from  the  lower  border  of  the  symphysis 
ossis  pubis,  from  the  posterior  surface  of  the  os  pubis,  and  from  the 
obturator  fascia  as  far  back  as  the  ilio-pectineal  eminence.  From  this 
somewhat  extensive  origin  the  fibres  pass  meso-dorsad,  passing  by 
tlio  uretlira,  tlie  vagina,  and  the  rectum,  lying  cephalad  of  the  lower 
porlion  of  the  ilio-coccygeus,  and  arc  inserted  with  those  of  its  fellow 


252  ,  A  TEXT-BOOK  OF   GYNECOLOGY 

from  the  opposite  side  by  means  of  a  tendinous  expansion  into  tlie  ven- 
tral surface  of  the  coccyx  and  the  lower  part  of  the  sacrum,  the  more 
ventral  fibres  interlacing  directly  with  those  of  its  fellow  as  a  girdle 
posterior  to  the  rectum.  The  pubo-rectalis  lies  beneath,  or  caudad  of, 
the  ventral  portion  of  the  pubo-coccygeus,  from  which  it  is  separated 
ventrally  by  an  intermuscular  fascia.  It  arises  from  the  lower  jDortion 
of  the  symphysis  ossis  pubis,  or  from  the  beginning  of  the  descending 
ramus  and  the  cephalic  surface  of  the  urogenital  fascia.  Its  fibres 
usually  form  a  well-defined  muscular  loop  which  passes  dorsad,  encir- 
cling the  rectum  at  the  perineal  fiexure  where  it  becomes  continuous 
with  its  fellow.  In  jDassing  by  the  rectum,  some  of  its  fibres  enter  the 
wall  of  the  rectum,  gradually  become  tendinous,  and  pass  caudad  as  far 
as  the  cutaneous  surface.  A  few  fibres  also  pass  anterior  to  the  bowel 
between  it  and  the  vagina,  some  of  them  eventually  becoming  con- 
tinuous with  the  transversus-perinsei  muscle  of  the  opposite  side.  The 
jjubo-coccygeus  and  the  pubo-rectalis  together  form  what  is  generally 
termed  the  levator-ani  muscle,  and  are  the  most  important  muscles  of 
the  pelvic  floor.  They  produce  the  characteristic  perineal  flexure  of 
the  rectum  and  vagina  and  form  the  chief  support  of  the  pelvic  viscera. 
They  must  undergo  the  greatest  elongation  during  the  dilatation  of  the 
pelvic  outlet  for  the  passage  of  the  child,  and,  therefore,  are  most 
liable  to  suft'er  rupture  or  laceration,  as  will  be  shown  later.  The  more 
ventrally  placed  fibres  pass  almost  directly  ventro-dorsad,  while  on 
frontal  section  the  muscular  plane  slopes  from  the  periphery  toward 
the  centre  and  cephalo-caudad.  In  the  space  between  the  opposite 
muscles  ventrally  pass  the  vagina  and  urethra,  and  it  is  extremely  im- 
portant to  clearly  understand  the  relations  of  these  muscles  to  the 
lateral  wall  of  the  vagina.  The  normal  virgin  vagina  is  not  a  simple 
straight  tube.  In  passing  from  without  inward  the  general  direction 
of  the  vagina,  for  a  distance  of  1.5  to  3  centimetres  within  the  hymen 
is  dorso-cephalad.  At  this  point  a  distinct  change  in  direction  takes 
place  and  the  vagina  passes  almost  directly  dorsad.  The  point  of  angu- 
lation lies  opposite,  and  corresponds,  to  the  perineal  flexure  of  the 
rectum,  and  is  produced  by  the  pubo-coccygeus  and  the  pubo-rectalis 
muscles  encircling  these  canals  at  this  point  and  drawing  them  for- 
ward, or  in  a  ventral  direction.  With  the  finger  introduced  into  the 
vagina,  one  is  able  easily  to  recognise  the  point  of  angulation,  and 
distinctly  to  feel  the  edge  of  the  pubo-rectalis  muscle  through  the  lat- 
eral wall  of  the  vagina,  as  it  passes  in  its  course  toward  the  symjjhysis. 

"  An  incision  through  the  lateral  wall  of  the  vagina  1  to  2  centi- 
metres to  the  inner  side  of  the  hymen  or  its  remains  will  expose  the 
median  edge  of  this  muscle.  It  may  easily  be  dissected  up  almost  from 
its  origin  from  the  symphysis  ossis  pubis  to  the  rectum,  and  in  passing 
by  the  vagina  its  fibres  do  not  enter  or  form  an  attachment  directly  to 
the  vaginal  wall.  The  muscle  varies  from  3  to  6  millimetres  in  thick- 
ness and  extends  in  connection  with  the  pubo-coccygeus  laterally  to  the 
wall  of  the  pelvis,  the  plane  in  the  transverse  direction  being  oblique 


THE   PELVIC   FLOOR  AND   ITS  INJURIES  253 

to  the  wall  of  the  vagina.  That  portion  of  the  vagina  lying  internal 
to  the  point  of  angulation  or  perineal  flexure,  and  which  composes  by 
far  the  major  portion  of  the  canal,  lies  in  its  ventro-dorsal  plane  almost 
parallel  with  the  muscular  plane,  and  rests  on  it,  the  rectum  alone  in- 
tervening. Contraction  of  the  muscles  of  this  layer  tends  to  increase 
the  perineal  flexure  of  the  rectum  and  vagina  by  drawing  the  parts  in  a 
ventro-cephalic  direction,  and  the  opening  through  the  muscular  floor 
is  thereby  maintained  ventrad  of  the  line  of  gravity.  The  weight  of  the 
pelvic  organs  is  thus  brought  to  bear  on  the  muscular  layer  of  the  pelvic 
floor;  that  mass  of  tissue  ordinarily  called  the  perineal  body  lying  be- 
tween the  rectum  and  the  vagina,  and  extending  from  the  inner  muscu- 
lar floor  of  the  pelvis  to  the  cutaneous  surface,  has  little  or  nothing  to 
do  with  sustaining  the  pelvic  organs."     (Harris,  ibid.) 

The  pubo-coccygeus  and  the  pubo-rectalis  muscles,  considered  joint- 
ly as  the  levator-ani  muscle,  are  graphically  described  by  Dickinson 
{American  Journal  of  Obstetrics)  as  resembling  a  horseshoe.  Without 
reference  to  accurate  anatomical  details  he  says  that  "  it  is  like  a  sling 
attached  to  the  pubes  in  front,  its  sweep  reaching  horizontally  back- 
ward to  encircle  the  rectum  and  vagina  like  a  collar.  It  sustains  the  re- 
lation of  an  independent  encircling  constrictor  to  the  rectum  and  vagina, 
both  of  which  are  drawn  by  it  in  the  direction  of  the  pubes.  It  is  a 
vohmtary  muscle  with  the  capacity  of  lifting  from  10  to  27  pounds.  In 
cases  in  which  it  is  inordinately  developed  it  may  be  a  serious  barrier 
to  the  sexual  relations  while  its  spasmodic  excitation  is  the  frequent 
cause  of  dyspareunia  and  vaginismus." 

Meyer  designated  the  internal  muscular  layer  of  the  pelvic  floor  as 
the  diaphragma  pelvis  proprium.,  and  there  has  been  a  disposition  among 
other  writers  to  speak  of  this  layer  as  the  pelvic  diaphragm.  But  this 
nomenclature  is  both  erroneous  and  misleading.  The  word  diaphragm, 
whether  employed  in  mechanics  or  biology,  conveys  the  meaning  of  "  a 
partition  or  septum  which  separates  one  cavity  from  another."  The 
most  extravagant  license  can  not  conjure  into  existence  a  cavity  below 
the  internal  muscular  layer  of  the  pelvic  floor.  If  the  term  pelvic  dia- 
phragm is  to  be  employed  at  all,  it  shou.ld  be  restricted  to  that  parti- 
tionlike arrangement  of  structures  at  the  utero-vaginal  junction  which 
divides  the  recognised  cavity  of  the  pelvis  from  the  cavities  of  the 
vagina,  rectum,  and,  in  part,  of  the  bladder. 

Injuries  of  the  pelvic  floor  may  embrace  any  of  the  recognised 
varieties  of  wounds,  such  as  contused,  incised,  or  lacerated.  They  may 
be  restricted  to  the  skin,  or  they  may  involve  the  external  muscular 
layer  (perineum),  or  only  the  deeper  muscular  layer,  or,  to  a  greater  or 
less  extent,  the  whole  of  the  structures  of  the  pelvic  floor.  In  this 
chapter  we  shall  confine  attention  to  those  injuries  which  affect  (a)  the 
external  muscular  layer  (perineum),  and  (&)  the  internal  muscular  layer. 

Lacerations  of  the  Perineum. — Injuries  of  the  external  muscular 
layer  are  cliicfly  restricted  to  tlie  /lerineum  and  are  ordinarily  discussed 
under  the  title  of  lacerations  of  the  perineum.     These  injuries  rarely 


254 


A  TEXT-BOOK  OF  GYNECOLOGY 


result  from  external  violence,  but  the  traumatism  upon  which  they 
depend  is  generally  an  incident  of  parturition. 

The  traumatisms  inflicted  in  this  region  are  generally  considered 
and  treated  as  lacerated  wounds.  Still,  there  are  instances  in  which 
the  injury  may  be  classed  both  as  a  contusion  and  a  laceration,  and 
upon  a  proper  conception  of  the  true  nature  of  the  trauma  the  treat- 
ment will,  in  a  great  measure  depend. 

Varieties. — The  varieties  of  these  lacerations,  or  tears,  must  be  con- 
sidered from  the  standpoint  of  the  direction  taken  by  the  tear.  This 
will  be  governed  by  the  presenting  part  of  the  child  that  comes  in  con- 
tact with  the  least  resistant  or  most  inelastic  structure,  the  force  of  the 
labour  pains,  and  the  anatomic  construction  at  the  point  of  impinge- 
ment. 

It  must  be  remembered  that  the  perineal  structure,  as  a  whole,  is  a 
complex  arrangement  of  muscles,  ligaments  or  tendons,  fasciae,  and  ves- 
sels and  nerves,  so  interwoven  and  superimposed  as  to  resist  a  great 
amount  of  force.  One  of  the  functions  of  the  perineum  being  to  close 
the  introitus  vulva^  by  the  contraction  of  the  sjshincter  vagint"B  and 

levator-ani  muscles,  it  is  drawn 
or  held  forward  by  them,  pro- 
ducing an  abrupt  angle  with 
the  lower  portion  of  the  birth 
canal;  so  that,  in  the  process 
of  descent,  the  presenting  part 
comes  into  contact  with  a  de- 
cided obstruction,  and,  should 
it  be  wanting  in  elasticity  or 
resiliency,  the  structure  is  sure 
to  be  injured.  A  tear  occurs 
at  the  point  of  least  resistance, 
whether  at  this  point  be  situ- 
ated a  muscle,  tendon,  or  fas- 
cia. This  tear  will  take  the 
direction  of  the  course  of  the 
fibres  composing  the  integral 
part  at  which  the  force  is 
spent  (Fig.  94);  for  the  rea- 
son that  it  does  not  require 
so  much  force  to  split  such  a 
structure  as  it  does  to  sever  it 
at  right  angles.  Should  a  tear 
occur  along  the  course  of  the 
central  tendon  it  may  be  de- 
nominated a  central  tear;  if 
along  the  fibres  of  the  transversus  peringei  muscle  or  the  transverse  fibres 
of  the  triangular  Hgament,  a  lateral  tear,  with  the  prefix  "right"  or 
"  left,"  as  the  case  may  be.    The  central  rupture  is  regarded  by  most  au- 


FiG.  94—"  This  tear  will  take  the  direction  of  the 
course  of  the  fibres  composing  the  integral  part 
at  which  the  force  is  spent." — Doesett. 


THE   PELVIC  FLOOR  AND  ITS  INJURIES  255 

thors  as  far  the  more  frequent,  but  this  is  not  the  experience  of  Dorsett. 
Out  of  1,006  ruptures  of  the  perineum  occurring  at  the  St.  Louis 
Female  Hospital  from  July  15,  1887,  to  March  3,  1892,  there  were  296 
central  ruptures,  237  left  lateral,  199  right  lateral,  and  10  ruptures  of 
the  third  degree,  or  into  the  rectum,  being  more  or  less  central.  The 
remainder  were  of  a  superficial  nature,  or  ruptures  of  the  first  degree. 
So  great  is  the  tendency  for  the  line  of  tear  to  follow  the  fibres  of  the 
different  tissues  forming  the  perineum,  that  there  are  instances  in 
which  the  tear,  starting  at  the  raphe,  runs  along  the  central  tendon, 
here  and  there  breaking  a  fibre  and  getting  a  little  farther  to  one  side 
until  the  sphincter  ani  is  reached  and  penetrated;  which  muscle,  on 
account  of  its  peculiar  circular  form,  may  lead  the  tear  around  the  anus, 
almost  or  completely  enucleating  the  lower  rectum  from  the  surround- 
ing structures,  or  it  may  pass  on  backward  to  the  fibres  of  the  coccygeal 
ligament  and  split  them  till  it  reaches  a  point  at  or  near  the  tip  of  the 
coccyx.  Two  cases  of  enucleation  of  the  lower  rectum  from  these 
severe  tears  have  been  observed  by  Dorsett. 

A  laceration  may  start  at  the  fourchette  and  take  a  straight  back- 
ward course,  following  the  raphe  for  a  short  distance,  when,  on  ac- 
count of  a  particularly  strong  fibre  or  set  of  fibres  of  the  triangular  liga- 
ment or  transversus  peringei  muscle,  it  may  take  a  different  course,  pro- 
ducing a  very  irregular  wound.  Lacerations  sometimes  take  a  shape 
not  unlike  the  letter  L  or  an  inverted  Y  or  T. 

When  the  head  is  in  the  first  or  second  obstetrical  position  and  there 
is  not  a  great  disproportion  between  the  child's  head  and  the  maternal 
parts,  and  when  the  patient  is  tractable  and  can  be  controlled,  the 
levator-ani  muscle,  as  a  rule,  escapes  injury.  When  an  occiput  posterior 
position  is  met  with,  the  deeper  perineal  structures  are  apt  to  suffer, 
whether  the  delivery  is  instrumental  or  not.  This  is  due  to  the  fact 
that  flexion  can  not  take  place  and  the  occiput  engages  the  posterior 
wall  of  the  vagina  and  ploughs  its  way  through  the  perineum,  tearing 
the  levator-ani  and  other  deep  muscles  on  its  way  outward.  Occasion- 
ally, these  posterior  positions  may  cause  what  is  known  as  perforating 
rupture.  In  other  words,  the  perineum  may  be  perforated  by  the 
child's  head  in  such  a  way  that  the  fourchette  and  sphincter  ani  may 
remain  intact.     Such  injuries  are,  however,  fortunately  rare. 

A  most  remarkable  case  of  perforating  rupture  of  the  perineum  is 
related  by  Liszt  (Monatsschrift  fiir  GehurtsMilfe  unci  Gynakologie).  The 
subject  was  a  primipara,  aged  twenty  years,  who  had  a  normal  pelvis  and 
was  in  labour  thirteen  and  a  half  hours.  A  swelling  the  size  of  a  goose's 
egg  appeared  over  the  perineum  and  gradually  increased  in  size  until  it 
ruptured  two  hours  later.  The  child,  which  presented  by  the  breech, 
was  expelled  through  the  opening,  but  the  head  had  to  be  extracted. 
The  fourchette  and  rectum  were  uninjured. 

For  the  purpose  of  description,  lacerations  of  the  perineum  may  be 
described  as  degrees  of  injury,  according  to  the  extent  of  solution  of 
oriliriiiity.     As,  for  example,  a  laceration  through  the  skin,  mucous. 


256  A  TEXT-BOOK  OF   GYNECOLOGY 

submucous,  and  subcutaneous  cellular  tissue,  and  as  far  as  the  muscle 
but  not  into  it,  may  be  termed  a  laceration  of  tlie  first  degree;  if  through 
the  skin,  mucous  membrane,  submucous  and  subcutaneous  cellular 
tissue,  and  the  muscular  structures  to,  or  into,  the  external  sphincter- 
ani  muscle,  a  laceration  of  the  second  degree;  if  through  all  the  previ- 
ously mentioned  tissues,  and  also  through  the  anal  sphincter  into  the 
rectum,  a  laceration  of  the  tliird  degree. 

Prophylaxis.- — In  the  conduct  of  a  case  of  labour  it  should  be  a 
matter  of  the  utmost  concern  to  the  obstetrician  to  guard  against  a 
rupture  of  the  perineum,  the  time  for  the  most  watchful  attention 
being  at  the  close  of  the  second  stage  of  labour;  for,  when  the  present- 
ing 23art  is  pressing  uj)on  the  perineum,  the  tenesmus  becomes  so  great 
that  the  inclination  to  strain,  as  at  stool,  becomes  almost  irresistible. 
Still,  in  many  instances,  if  the  patient  is  directed  to  "  breathe  out " 
and  to  "  take  short  breaths,"  she  may  control  herself  to  such  a  degree 
that  the  head  may,  even  in  a  primiparous  woman,  slip  over  the  peri- 
neum Avithout  injuring  it  beyond  a  slight  tear  of  the  fourchette.  Yet 
it  must  not  be  forgotten  that  the  maintenance  of  flexion  of  the  child's 
head  is  the  desideratum,  and  it  is  the  duty  of  the  obstetrician,  by  con- 
stant manual  effort,  so  to  press  the  occiput  downward  toward  the  hollow 
of  the  sacrum,  that,  by  the  proper  amount  of  moulding  of  the  head,  the 
occiput  can  come  well  up  under  the  pubic  arch.  When  this  stage  is 
reached,  the  force  now  to  be  exerted  is  in  exactly  the  opposite  direction 
— that  of  extension — and  is  exercised  by  placing  the  palm  of  the  right 
hand,  not  u^jon  the  mother's  perineum,  as  was  taught  by  the  older 
writers,  but  upon  the  part  of  the  child's  head  that  shows  in  the  cleft 
of  the  vulva,  till  the  parietal  eminences  are  about  to  escape,  when 
the  left  hand  relieves  the  right,  and  the  index  and  middle  fingers  of  the 
right  hand  are  carried  into  the  rectum  and  hooked  under  the  supra- 
orbital arches.  Gentle  traction  is  now  made  with  the  two  fingers  of 
the  right  hand  upward  toward  the  pubic  arch,  while  the  left  hand 
holds  the  head  well  against  the  arch.  As  soon  as  there  is  shown  to  be 
some  progress,  the  two  fingers,  already  in  the  rectum,  are  carried 
farther  upward,  and  the  lower  border  of  the  superior  maxillary  bone 
(in  the  child's  mouth)  is  reached,  when  traction  is  made  upon  it,  and 
latterly  the  child's  chin  is  substituted  for  the  maxilla.  During  this  pro- 
cess of  "  shelling  out  the  child's  head,"  very  effective  assistance  can  be 
rendered  by  the  nurse  or  assistant,  by  the  insinuation  of  the  fingers 
between  the  child's  occiput  and  the  pubic  arch,  and  by  pushing  down 
the  upper  vaginal  commissure  which  engages  the  back  of  the  child's 
neck,  like  a  collar.  This  rule  should  be  followed  whether  the  forceps 
is  used  or  not.  In  the  great  majority  of  instances  the  forceps  is  only 
necessary  to  bring  down  the  head  into  the  vulva  and  is  then  taken  off; 
the  remainder  of  the  delivery  can  be  accomplished  in  the  manner  indi- 
cated above.  In  the  delivery  of  all  cases,  irrespective  of  presentation  or 
position,  traction,  manual  or  instrumental,  should  be  in  the  direction  of 
the  axes  of  the  birth  canal  for  the  preservation  of  the  perineum.     This 


THE  PELVIC   FLOOR  AND   ITS   INJURIES  257 

rule  should  be  strictly  adhered  to  at  the  outset.  Still,  with  the  utmost 
care  and  good  judgment,  the  perineum  will  be  ruptured  in  a  certain 
proportion  of  cases.  J.  W.  Bullard  (Western  Medical  Review,  Novem- 
ber 16,  1898),  after  having  consulted  Byford,  Munde,  Martin,  Hirst, 
Baldy,  Coe,  and  Montgomery,  as  to  proportion  of  lacerations  during 
first  labours,  has  found  it  to  be  about  30  per  cent. 

Consequences. — The  immediate  consequences  of  laceration  of  the 
perineum  are  according  to  the  degree  of  injury  sustained.  If  the  lacera- 
tion is  of  the  first  degree,  the  consequences  are  trivial.  If  of  the  second 
■or  third  degree,  the  normal  involution  of  the  vagina  and  vulva  is  more  or 
less  interfered  with,  and  the  danger  of  sepsis  greatly  augmented.  On 
account  of  the  resulting  torn  and  lacerated  open  wound,  pathogenic 
organisms  gain  ready  access.  If  the  laceration  extends  into  the  rec- 
tum through  the  sphincter-ani  muscle,  the  inability  to  retain  the  faeces 
iind  gas  will  render  the  patient  a  miserable  sufferer. 

The  remote  consequences,  when  the  laceration  is  of  the  second  or 
third  degree,  are  many  and  not  confined  to  the  site  of  injury.  For  it 
must  be  remembered  that  the  perineum  is  the  support  upon  Avhich  rest 
the  internal  organs  of  generation  as  well  as  a  part  of  the  weight  of  the 
bladder;  so  that  an  impairment  of  this  structure  necessarily  disqualifies 
these  organs  from  performing  their  functions  in  a  normal  manner. 

When  the  laceration  extends  to  the  anal  sphincter  and  is  deep 
■enough  to  involve  the  levator  ani,  the  transverse  muscles,  and  the 
transverse  fibres  of  the  triangular  ligament  as  well  as  the  different  layers 
■of  fascia,  the  anterior  wall  of  the  rectum  and  the  posterior  wall  of  the 
bladder  are  robbed  of  their  natural  support,  and  a  sagging  of  these 
organs  is  the  consequence.  As  soon  as  the  solution  of  continuity  takes 
place,  the  divided  ends  of  muscles  retract,  and,  in  time,  by  the  pro- 
cess of  healing,  will  be  covered  by  mucous  membrane,  which  does  not 
give  strength  but  allows  a  pouching  downward  of  these  organs.  Strain- 
ing in  the  act  of  defecation  or  micturition  augments  the  trouble,  and, 
in  the  case  of  the  bladder,  a  cystocele — in  the  case  of  the  rectum,  a  rec- 
tocele — is  formed.  These  abnormal  pouches  grow  progressively  larger 
and  progressively  give  more  and  more  trouble.  In  the  case  of  the  blad- 
der, the  loss  of  its  posterior  support,  viz.,  the  perineum,  together  with 
the  tearing  away  of  its  natural  moorings  from  their  normal  attachment 
around  the  internal  aspect  of  the  pubis  by  the  passage  of  the  child 
through  the  birth  canal,  leaves  nothing  to  hold  it  up,  and  a  sagging  of 
the  viscus  is  the  result.  This  sagging  down  prevents  the  organ  from 
emptying  itself  completely,  and  a  decomposition  of  the  residual  urine 
soon  sets  up  an  often  intractable  cystitis. 

A  division  of  the  structures  composing  the  greater  portion  of  the 
perineum,  leaving  only  the  sphincter-ani  muscle,  allows  the  rectum 
to  pouch  forward,  thus  forming  the  condition  known  as  rectocele.  This 
tiirnoTir  is  increased  in  size  by  the  efforts  at  defecation,  for  the  reason 
that  tlio  anterior  wall  of  the  rectum  forms  almost  a  right  angle  to  the 
.anus,  and,  at  each  attempt  to  defecate,  this  angle  is  increased,  and 

1H 


258  A  TEXT-BOOK  OP  GYNECOLOGY 

the  pouch  or  sac  is  consequently  likewise  increased  in  size.  On  account 
of  the  inability  to  evacuate  thoroughly  the  contents  of  the  rectum,  a 
constipation  is  inaugurated,  which  tends  still  further  to  increase  the 
size  of  the  tumour. 

jSTot  alone  to  the  bladder  and  rectum,  is  the  mischief  done  by  a 
rupture  of  the  perineum.  The  vagina,  uterus,  and  uterine  adnexa, 
also  suffer.  The  lack  of  support  given  the  vaginal  walls  causes  them  to 
drag  the  uterus  downward,  stretching  its  suspensory  structures — viz.,. 
the  broad  ligaments  on  either  side,  the  two  utero-sacral  ligaments  pos- 
teriorly, and  the  two  round  ligaments  anteriorly.  Nature  only  intended 
these  ligaments  to  act  as  "  guy  ropes,"  to  poise  the  uterus  in  the  pelvic 
cavity,  and  not  as  supports.  The  consequence  is  a  giving  way  of  these 
ligaments,  resulting  in  either  descensus  or  retro-deviations  of  the 
uterus  and  adnexa. 

The  restoration  of  the  pelvic  floor  is  demanded  in  all  cases  when 
the  injury  is  sufficient  to  cause  either  destruction  or  serious  deteriora- 
tion of  the  functional  power  of  this  structure.  When  injuries  are 
restricted  to  the  external  muscular  layer  (perineum)  the  impairment  of 
function  may  consist,  either  in  a  mere  enlargement  of  the  vaginal  out- 
let, with  a  consequent  tendency  to  rectocele  and  cystocele,  or,  if  the 
laceration  has  extended  through  the  recto-vaginal  septum,  dividing  the 
sphincter-ani  muscle,  the  consequent  loss  of  function  finds  expression 
in  fgecal  incontinence;  the  indication,  therefore,  is  for  the  repair  of 
what  are  ordinarily  designated  the  perineal  structures.  If,  on  the 
other  hand,  the  injury  involves  the  internal  muscular  layer  of  the 
pelvic  floor,  the  resulting  impairment  of  function  eventuates,  not  only 
in  a  tendency  to  rectocele  and  cystocele,  but  in  general  ptosis  of  the  pel- 
vic viscera;  the  manifest  indication  is,  consequently,  for  a  restoration  of 
integrity  and  tone  in  the  impaired  deep  muscles  of  the  pelvic  floor. 
When  both  layers  of  the  pelvic  floor  are  damaged,  as  is  the  case  in  prob- 
ably the  majority  of  instances,  the  resulting  operation,  to  be  curative, 
must  comprehend  a  restoration  of  all  the  injured  parts.  It  is  needless 
to  say  that  the  necessary  prelude  to  correct  treatment  must  consist  in 
careful  examination  and  accurate  diagnosis. 

The  immediate  operation  for  external  injuries  of  the  pelvic  floor, 
otherwise  called  lacerations  of  the  perineum — i.  e.,  the  operation  for 
restoration  of  the  parts  immediately  after  parturition — is  one  the  expe- 
diency of  which  must  be  determined  by  the  character  of  the  laceration 
and  the  condition  of  the  patient.  If  the  laceration  is  not  associated 
with  much  contusion,  if  the  line  of  cleavage  is  direct  and  the  surface 
smooth  and  of  easy  approximation,  and  if,  moreover,  the  patient's 
condition  is  such  as  to  admit  of  the  operation,  sutures  may  be  applied 
at  once  and  the  wound  closed.  If,  however,  the  laceration  is  of  the 
eccentric  variety,  if  the  tissues  are  bruised  and  the  proxim.al  surfaces 
seem  to  be  infiltrated  with  blood,  and  particularly  if,  in  the  presence 
of  these  conditions,  the  laceration  is  complete,  attempt  at  imme- 
diate repair  may  be  set  down  in  the  vast  majority  of  cases  as  a  mere 


THE   PELVIC   FLOOR  AND   ITS   INJURIES 


259 


unnecessary  and  fruitless  infliction  of  pain.  The  practitioner  in  Justice 
alike  to  himself  and  his  patient  should,  before  attempting  the  imme- 
diate repair  of  these  injuries,  explain  that  the  majority  of  such  opera- 
tions are  failures.  Union  may  be  said  to  occur  in  less  than  50  per  cent 
of  even  favourable  cases.     When  the  practitioner  deems  the  case  in 


Fig.  95. — Hemostatic 
forceps. — Kobe. 


Fig.  96.— Scalpel. 
— Kobe. 


Fig.  97. — Emmet's  left- 
angled,  right-curved 
scissors. — EoBB. 


Instruments  for 

Catheter,  glass  1 

Forceps,  hemostatic : 

Long 2 

Intermediate 2 

Small  (Fig.  95) 2 

Long  dressing 1 

Needles,    as    for    abdominal     sections 
(omitting  the  largest). 

Needle-holders 2 

Needle,  Reed's  curved 1 

Nozzle,  Edebohls's 1 


PerineorrJiapliy 

Packer,  vaginal 1 

Retractor,  small 1 

Intermediate 1 

Scalpels  (Fig.  96) 2 

Scissors,  right-angled 1  pair. 

Emmet's  left-angled  (Fig.  97)..  1      " 

Straight-pointed 1     " 

Sound,  uterine 1 

Tenaculum,  straight 1 

Tenacula,  curved 2 


hand  a  proper  one  for  immediate  repair,  he  should  recognise  that 
every  step  of  the  operation  should  be  done  with  the  strictest  antiseptic 
precautions.  The  patient  should  be  put  in  position  on  the  table  and 
the  vagina  should  be  carefully  irrigated,  preferably  with  lysol  or  car- 
bolic-acid solution;  if  the  mercuric  bichloride  is  used  the  solution  should 
not  be  stronger  than  1  to  4,000,  because  a  stronger  solution  coming  into 


260 


A  TEXT-BOOK  OF   GYNECOLOGY 


contact  with  the  raw  surfaces  of  the  wound  is  liable  to  cause  tissue 
changes  that  will  interfere  with  the  union.  After  cleansing  the  vagina, 
the  upper  part  of  that  canal  should  be  carefully  packed  with  sterilized 
gauze,  to  prevent  the  escape  of  the  lochia  during  the  progress  of  the 
operation.  After  having  again  cleansed  the  wound,  interrupted  sutures 
of  sterilized  silkworm  gut  should  be  inserted,  with  careful  observance  of 
the  principles  governing  their  application,  as  set  forth  in  the  paragraph 
relating  to  the  elective  operation  of  perineorrhaphy. 

Operations  for  Incomplete  Laceration  of  the  Perineum. — The  opera- 
tion for  the  repair  of  superficial  lacerations  of  the  perineum  is  very 
simple.     A  V-shaped  area  is  denuded  at  the  site  of  the  former  four- 

chette  (Fig.  98),  and  is 
closed  by  interrupted  su- 
tures (Fig.  99),  the  re- 
sulting line  of  approxi- 
mation representing  the 
letter  Y. 

Emmet's  Operation. — 
The  patient,  after  having 
been  antiseptically  pre- 
pared and  anassthetized, 
is  placed  u]3on  her  back, 
her  buttocks  at  the  edge 
of  the  table,  her  legs 
thoroughly  flexed  and  in- 
trusted to  assistants,  or 
preferably,  to  the  me- 
chanical appliances 
which  constitute  a  part 
of  the  modern  operat- 
ing table  (Fig.  100),  the 
clothing  worn  during 
operations  being  omitted 
from  the  picture  in  order 
to  show  better  the  posi- 
tion of  the  legs.  To 
hold  the  legs  in  a  flexed 
position  is  both  difficult 
for  the  assistant  and  not 
destitute  of  danger  to 
the  patient,  for  injuries 
have  happened  to  the 
hip  joint  by  injudicious 
pressure  upon  the  flexed 
leg.  Clover's  crutch  is  not  a  desirable  appliance  for  the  reason  that 
its  mechanism  is  calculated  to  interfere  with  respiration  and  to 
become  an  embarrassment  to  anaesthesia.     As  soon  as  the  patient  is 


Fig.  98. — "A  V-sliaped  area  is  denuded  at  the  site  of 
tlie  former  fourehette." — Eebd. 


THE   PELVIC  FLOOR  AND   ITS  INJURIES 


201 


put  in  this  position  and  the  labia  are  retracted,  the  posterior  wall  of 
the  vagina  will  appear  as  a  projecting  mass  within  the  vagina  (recto- 
cele,  Fig.  86).  A  tenaculum  is  fixed  in  the  middle  and  at  the  apex  of 
this  mass,  which  is  now 

drawn   forward   and   up-       f       ~  ^  T^^ 

ward  toward  the  pubes; 
as  this  is  done  the  trac- 
tion thereby  induced  will 
make  apparent  two  folds, 
one  on  either  side,  lead- 
ing from  the  point  of  the 
tenaculum  to  each  lateral 
sulcus  of  the  vagina.  A 
tenaculum  is  then  hooked 
into  the  caruncle  caused 
by  muscular  retraction 
on  either  side  of  the  vag- 
inal outlet,  and  upon  the 
tenacula  thus  placed  lat- 
eral traction  is  made  by 
assistants.  A  gutterlike 
fold  is  thus  formed,  the 
external  end  beginning 
at  the  caruncle  and  ex- 
tending upward  into  the 
lateral  sulcus  where  it 
coalesces  with  the  fold 
from  the  central  point  of 
traction  maintained  by 
the  tenaculum  drawn  up- 
ward toward  the  jDubes, 
and  another  tenaculum  is 
now  placed  at  the  site  of 
the  fourchette,  midway 
between  the  two  last 
named. 

The  traction  made  in 
this  way  indicates  the 
area  to  be  denuded,  while 
the  approximation  of  the 
two  lateral  tenacula  and 
the    final    infolding    and 


Fig.  99. — " .  .  .  Closed  by  interrupted  sutures,  the  re- 
sulting line  of  approximation  representing  the  letter 
Y."— Reed  (page  260). 


the  one  in  the  vaginal  wall  will  show 
approximation  of  tissue  that  is  to  be 
accomplished  by  the  operation.  Again  separating  these  three  points, 
and  re-establishing  the  upward  and  lateral  tension,  the  operator 
can  see,  in  clear  outline,  the  area  which  is  to  be  denuded.  The 
margins  of  the  folds  induced  by  the  traction  are  the  indications  for 
the  incision,  which  is  carried  along  the  crest  of  one  lateral  fold  to 


202  A  TEXT-BOOK  OF   GYNECOLOGY 

the  bottom  of  the  sulcus  on  the  same  side,  and  from  the  bottom  of 
that  sulcus  to  the  central  tenaculum,  on  the  posterior  vaginal  wall;  it 
is  then  carried  from  this  same  central  point  to  the  bottom  of  the 
sulcus  on  the  opposite  site  of  the  vagina,  and  along  the  crest  of  that 

lateral  fold  to  the  vulvar 
margin;  the  two  ends  of 
this  really  continuous  in- 
cision are  now  united  by 
carr3dng  an  intermediate 
incision  from  one  lateral 
tenaculum  directly  across 
to  the  opposite  lateral 
tenaculum.  The  territory 
thus  outlined  is  next  de- 
nuded, after  which  the  me- 
dian tenaculum  on  the  pos- 
terior wall  of  the  vagina  is 

Fig.  100.—"  The  patient  is  placed  upon  her  back,  her        clrawn  down  to  a  level  with 

legs  thoroughly  flexed."— Keed  (page  260).  the  lateral  carunculse.     Su- 

tures of  silver  wire  are  em- 
ployed and  are  inserted  first  into  one  lateral  triangle  and  next  into  the 
other  lateral  triangle  of  the  wound.  They  are  passed  an  eighth  of  an 
inch  back  of  the  margin,  and  traverse  first  the  mucous  membrane  and 
then  the  underlying  muscularis;  are  crossed  over  to  the  other  margin 
of  the  same  triangle  and  are  passed  out  from  beloAv  upward,  including 
first  the  muscularis  and  then  the  mucosa.  The  sutures  are  inserted 
about  one  fourth  of  an  inch  apart  and,  in  passing  from  one  side  to  the 
other  of  the  respective  triangles,  they  are  made  to  define  a  V-shaped 
course,  the  apex  of  the  letter  pointing  downward  (Fig.  101).  This  is 
accomplished  by  inserting  the  needle  and  bringing  it  downward  to  the 
median  line  of  the  triangular  space,  drawing  it  out,  reinserting  it  at 
the  point  of  exit,  and  directing  it  upward  and  inward.  After  the 
sutures  have  been  placed  in  first  one  and  then  the  other  lateral  triangle, 
the  "crown  suture"  is  inserted  (Fig.  101).  This  suture  is  recognised 
by  Emmet  as  the  one  of  principal  importance  in  the  entire  operation 
and  is  inserted  at  the  point  of  the  carnncular  depression  on  one  side, 
deeply  enough  to  embrace  within  its  sweep  the  levator-ani  muscle.  It  is 
brought  out  on  the  denuded  surfaces,  passed  over,  and  is  inserted 
through  the  cellular  tissue  underlying  the  tip  of  the  central  mucous 
tongue.  It  is  then  crossed  over  to  the  other  side,  is  inserted  deeply 
enough  to  include  within  its  sweep  the  levator-ani  muscle,  and  is 
brought  out  Just  back  of  the  caruncular  depression  of  that  side.  A 
second  suture  an  eighth  of  an  inch  from  the  foregoing  may  be  similarly 
inserted  if  deemed  expedient.  Interrupted  sutures  are  now  passed 
from  one  side  to  the  other,  between  the  "  crown  suture "  and  the 
median  perineal  tenaculum,  at  intervals  of  about  one  fourth  of  an 
inch.     The  sutures  are  now  tied,  beginning  with  those  at  the  apex  of 


THE   PELVIC  FLOOR  AND  ITS  INJURIES 


263 


first  one  and  then  the  other  triangle,  the  resulting  approximated  wound 
resembling  the  letter  Y.  Care  should  be  taken  in  tying  the  sutures; 
for,  if  tied  too  tightly,  they  may  induce  necrosis  from  pressure.  It  may 
be  taken  as  a  safe  rule  that  a  suture  is  too  tight  whenever  it  blanches 
the  tissues  that  it  compresses. 

The  foregoing  description  is  intended  to  convey  a  conception  of 
the  technique  as  employed  by  Enunet,  and  as  yet  practised  by  him 
and  his  numerous  fol- 
lowers. Many  of  the  lat- 
ter, however,  while  fol- 
lowing practically  every 
other  detail  of  Emmet's 
technique,  substitute 
other  suture  material; 
McMurtry,  for  instance, 
closes  the  lateral  trian- 
gles with  formalinized 
catgut,  using  silkworm 
gut  for  the  "  crown  su- 
tures "  and  for  the  extra- 
yaginal  sutures.  From 
the  fact,  however,  that 
formalinized  catgut  en- 
dures within  the  tissue 
from  fourteen  to  twenty- 
one  days- — a  longer  pe- 
riod than  the  interrupted 
sutures  are  ever  retained 
— the^  expediency  of  in- 
serting buried  "  crown 
sutures  "  of  this  material 
is  well  worthy  of  consid- 
eration. 

Reed's  method  of  su- 
turing is  as  follows:  The 
denudation  is  made  in 
the  same  way  as  in  Em- 
met's operation — but  the 
closure  is  effected  en- 
tirely  by   means    of   the 

buried  formalinized  catgut  suture.  The  crown  suture  is  first  in- 
serted. A  heavy  curved  needle  armed  with  strong  catgut  is  passed 
from  left  to  right  through  the  cellular  layer  of  the  mucous  tip;  it 
is  then  inserted  a  little  to  the  right  of  the  median  line  and  carried 
deep  enough  to  catch  in  its  sweep  the  levator  ani  on  the  patient's 
left  side.  It  is  brought  out  beneath  the  cutaneous  surface,  and  is 
carried  to  the  opposite  side  and  inserted  beneath  the  cutaneous  sur- 


FiG.  101. — "  After  the  sutures  have  been  placed  in  first 
one  and  then  the  other  lateral  triangles,  the  crown 
suture  is  inserted." — Eeed  (page  262). 


264 


A  TEXT-BOOK  OF   GYNECOLOGY 


face,  being  made  to  embrace  in  its  sweep  the  levator  ani  of  the  patient' s-- 
right  side  (Fig.  103),  when,  being  drawn  taut,  it  will  show  the  lines 
of  approximation  (Fig.  102).  If  the  laceration  is  very  deep  and  the 
separation  is  very  pronounced,  another  crown  suture  of  the  same  ma- 
terial is  inserted  in  the 
same  way;  the  ends  of  the 
crown  suture,  or  of  both 
of  them  if  two  are  used, 
are  left  long  and,  for  the 
present,  untied.  The 
wound  is  then  closed  by 
beginning  on  the  inside 
near  the  apex  of  the  left 
triangle,  inserting  the 
suture  through  the  deep 
connective  tissue  and  the 
muscularis,  and  bringing 
it  out  through  the  edge  of 
the  mucosa;  it  is  then 
carried     across     and 


m- 


FiG.  102.- 


serted  through  the  edge 
of  the  mucosa,  through 
the  muscularis,  and  the 
deep  connective  tissue. 
The  suture  is  now  tied 
and  the  short  distal  end 
alone  is  cut  away.  This 
gives  the  suture  its  an- 
chorage. (See  Abdomi- 
nal Section.)  After  this- 
the  needle  is  made  to  de- 
fine the  same  circuit  at  in- 
tervals of  one  quarter  of 
an  inch,  or  less,  until  the 
lateral  triangle  is  closed. 
The  needle  is  then  carried  through  the  submucous  connective  tissue  to 
the  apex  of  the  other  triangle,  when,  without  further  preliminary  fixa- 
tion, it  is  made  to  approximate  the  margins  of  the  wound  as  in  the  pre- 
ceding triangle  (Fig.  103).  When  both  lateral  triangles  have  thus  been 
closed  to  the  crotch  of  the  Y,  this  suture  is  fixed  by  tjdng  it  in  the 
deep  cellular  structures.  The  crown  suture  is  now  tied,  the  knot  being 
on  the  inner  surface  of  the  approximated  tissue.  The  remaining  peri- 
neal wound  is  then  closed  by  an  intercutaneous  suture  (see  Abdominal 
Section),  forming  the  stem  of  the  Y.  In  some  cases  it  is  well  to  fortify 
the  approximation  with  a  supplementary  serpentine  suture,  passed  sub- 
cutaneously  (Fig.  109).  The  advantages  of  this  method  of  closure  are 
that  it  insures  the  best  possible  approximation  of  the  parts;  it  gives  the 


-"  Being  drawn  taut  it  will  show  the  lines  of 
approximation." — Reed. 


THE  PELVIC   FLOOR  AND  ITS  INJURIES 


265 


patient  less  pain  after  operation;  it  is  less  liable  to  infection;  and  there 
is  no  occasion  to  remove  sutures. 

Various  modifications  of  Emmet's  operation  have  been  made,  many 
of  them,  unfortunately,  ignoring  its  sound  philosophic  principles; 
others,  however,  while  observing  the  principles  of  Emmet,  differ  from, 
his  operation  chiefly  in  the  manner  of  execution.  One  of  the  most 
valuable  of  these  innovations  is  the  procedure  of  A.  Palmer  Dudley,  the 
essential  point  of  which 
is  to  take  a  stitch  which 
will  draAV  up  all  the 
posterior  mucous  mem- 
brane at  the  middle  of 
the  posterior  wall,  so  that 
none  of  it  can  interpose 
itself  afterward  when  the 
parts  containing  the 
tendinous  centre  of  the 
muscular  floor  of  the  pel- 
vis are  drawn  into  ap- 
position. This  elimi- 
nates the  downward-pro- 
jecting tongue  of  mucous 
membrane  left  by  Em- 
met in  his  denudation. 
When  a  rectocele  is 
present,  the  denudation 
is  extended  upward  to 
the  crest  of  the  pre- 
senting pouch,  forming 
a  triangle  the  apex  of 
which  is  in  the  medi- 
an line  of  the  posterior 
vaginal  wall.  The 
wound  is  closed  by  a 
series  of  interrupted  cat- 
gut sutures,  the  ends  of 
which  are  tied  externally. 
In  passing  these  sutures 
in  cases  not  complicated 
with  rectocele,  the  nee- 
dle is  inserted  through 
the  cutaneous  margin 
and  carried  back  coinci- 

dently  with  the  long  axis  of  the  denudation  for  a  distance  of,  perhaps, 
half  an  inch;  it  is  then  drawn  through,  reinserted  at  right  angles,  and 
brought  out  at  the  mucous  margin,  the  buried  portion  of  the  suture 
making  a  lottor  L;  tlie  snture,  next  carried  over  to  the  opposite  side  at 


Fig.  103. — "The  needle  is  carried  through  the  submu- 
cous connective  tissue  to  the  end  of  the  other  trian- 
gle when  ...  it  is  made  to  approximate  the  margins 
of  the  wound  as  in  the  preceding  triangle."— Keed 
(page  264). 


266 


A  TEXT-BOOK  OF  GYNECOLOGY 


a  corresponding  point  and  inserted  through  the  mucous  margin  at  a 
distance  of  half  an  inch,  is  brought  out  in  the  midst  of  the  tissue,  and 
the  needle  reinserted  at  the  point  of  exit  and  brought  out  through  the 
cutaneous  margin,  the  buried  portion  of  the  suture  on  this  side  making 
the  letter  L  precisely  as  did  the  same  suture  on  the  other  side.  The 
second  suture  is  passed  in  precisely  the  same  way,  the  horizontal  and 
perpendicular  lines  being  parallel  with  those  of  the  preceding  stitch, 
from  which  it  is  distant  about  one  fourth  of  an  inch.  Four  or  more 
such  sutures  are  inserted  and  the  ends  are  tied  externally.  In  cases  in 
which  rectocele  is  present,  the  sutures  are  applied  beginning  at  the 
apex  of  the  upper  triangle.  The  needle  is  inserted  through  the  mucous 
membrane,  pointing  downward  and  inward  toward  the  median  line,  at 
which  point  it  is  brought  out;  reinserted  at  the  point  of  exit  and 
passed  through  the  tissues  upward  and  outward,  it  is  brought  out 
through  the  mucous  membrane  on  the  opposite  side  of  the  triangle  at  a 
point  directly  opposite  that  of  entrance.     The  buried  portion  of  the 

suture  thus  intro- 
duced is  in  the  shape 
of  a  letter  V.  Other 
sutures  are  applied  in 
the  same  manner,  the 
arms  of  the  V  gradu- 
ally widening  until, 
in  the  middle  of  the 
area  of  denuded  tis- 
sue, the  suture  is  di- 
rectly horizontal, 
while  those  inserted 
below  this  point  are 
parallel  with  it.  The 
sutures  are  now  tied, 
beginning  with  the 
upper  intra  vaginal 
one,  the  wound  when 
closed  making  a 
straight  line  along 
the  raphe  of  the  peri- 
neum, the  fourchette, 
and  the  median  line 
of  the  posterior  vag- 
inal wall.  Lawson 
Tait  adapted  the  flap- 
splitting  operation  to 
incomplete  lacera- 
tions of  the  perineum,  but  with  results  less  satisfactory  than  those 
following  the  Emmet  operation,  and  vastly  inferior  to  those  which 
follow  the  adoption  of  the  flap-splitting  jDrinciple  in  cases  of  complete 


Fig.  104.—"  The  condition  that  is  presented  at  examination." 
• — Keed  (page  267). 


THE   PELVIC   FLOOR  AND   ITS   INJURIES 


267 


laceration.  The  Emmet  operation  may  be  accepted  as  a  safe  work- 
ing method  in  incomplete  tears  of  the  perineum. 

Operations  for  Complete  Lacerations  of  the  Perineum. — When 
the  laceration  of  the  perineum  is  complete,  involving  the  separation 
of  the  recto-vaginal  sep- 
tum and  a  division  of  the 
sphincter-ani  muscle,  the 
resulting  condition  is 
much  more  embarrassing 
to  the  patient  and  much 
more  difficult  for  the  sur- 
geon. In  these  cases 
there  is  a  much  more 
complete  retraction  of  the 
perineal  structures,  a 
much  wider  gaping  of  the 
vaginal  orifice,  and  an 
incontinence  of  the  fgeces. 
The  condition  that  is  pre- 
sented at  examination 
(Fig.  104)  is  that  of  a  sep- 
tum with  only  a  narrow 
cicatrized  margin  which, 
if  denuded  by  the  ordi- 
nary trimming  process, 
would  afford  but  narrow 
surfaces  for  approxima- 
tion. This,  indeed,  was  a 
cause  of  failure  in  the  ma- 
jority of  the  older  opera- 
tions. To  obviate  this  dif- 
ficulty and  to  secure  wider 
margin  for  approxima- 
tion,    Lawson     Tait     hit 

upon  the  expedient  of  splitting,  rather  than  trimming,  the  septum. 
By  this  means,  turning  the  rectal  side  of  the  flap  into  the  rectum,  and 
the  vaginal  side  of  the  septum  into  the  vagina,  he  secured,  without  the 
loss  of  tissue,  approximating  surfaces  varying  from  half  an  inch  to 
as  much  more  as  might  be  deemed  desirable. 

Lawson  Tait's  Operation. — The  technique  of  the  flap-splitting 
operation  is  as  follows:  The  patient  is  carefully  prepared  with  due 
antiseptic  precautions  and  with  careful  attention  to  the  condi- 
tion of  the  bowels.  This  latter  point  is  of  extreme  importance  and 
should  consume  several  days  in  its  proper  accomplishment.  The 
bowels  should  be  relaxed  by  repeated  doses  of  salines  given  in  small 
quantity  and  at  frequent  intervals.  The  Hunyadi  or  Apenta  water  or 
a  mild  solution  of  sulphate  of  magnesium  may  be  given  every  few  hours 


Fig.  105.— "The  three  incisions  form  the  letter  H."- 
Reed  (page  268). 


268 


A  TEXT-BOOK  OF  GYNECOLOGY 


until  the  bowels  are  relaxed,  after  which  the  saline  should  be  kept  up 
at  longer  intervals  for  the  next  couple  of  days.  In  the  meantime  the 
diet,  while  abundant,  should  be  chiefly  of  the  liquid  variety.  Catharsis 
should  cease  at  least  twenty-four  hours  before  the  operation.  On  the 
morning  of  the  operation  one  or  two  high  enemas  should  be  given, 

washing  out,  not 
-ROTlIPHIfi3|  o^ly  ^^l^e  rectum,  but 
the  sigmoid  and  the 
colon.  No  opiates 
are  given  to  restrain 
the  bowels  either  be- 
fore or  after  the  op- 
eration. The  vagina 
is  now  thoroughly 
sterilized  and  the  pa- 
tient is  placed  on  the 
operating  table.  A 
bistoury  or,  prefer- 
ably, a  pair  of  keen- 
edged  scissors  curved 
on  the  edge  or  bent 
at  an  angle,  may  be 
employed  to  divide 
the  septum.  This  is 
done  by  carrying  the 
incision  from  one 
side  to  the  other,  be- 
tween the  vaginal 
and  rectal  layers  of 
the  septum,  to  the 
depth  of  about  half 
an  inch.  The  inci- 
sion is  next  carried 
out  to  either  side  to 
the  outer  margin  of 
the  distinctly  cica- 
tricial area.  Another 
incision  is  now  made, 
beginning  a  little  below,  and  a  trifle  to  the  outside  of,  the  um- 
bilicated  point,  indicating  the  location  of  one  end  of  the  retracted 
sphincter-ani  muscle.  The  incision  is  carried  upward  along  the 
outer  margin  of  the  cicatricial  area  to  its  upper  angle.  A  similar 
incision  is  now  made  on  the  opposite  side.  The  three  incisions 
unite  to  form  the  letter  H  (Fig.  105).  It  will  now  be  discovered  that 
by  bringing  the  two  upright  lines  of  the  H  into  approximation  with  the 
median  line  there  is  a  restoration  of  the  original  contour  of  the  parts. 
In  the  act  of  bringing  them  together,  the  vaginal  flap  and  the  rectal 


Fig 


106. — "  Other  operators  pass  these  sutures  through  the 
cutaneous  margin." — Keed  (page  269). 


THE   PELVIC  FLOOR  AND  ITS   INJURIES 


269 


flap  of  the  septum  separate,  approximating  the  broad  proximal  sur- 
faces. Before  the  sutures  are  applied,  a  little  more  dissection  may 
be  required  to  expose  the  buried  end  of  the  retracted  sphincter-ani 
muscle.  This  precaution  is  important.  Tait  was  in  the  habit  of 
closing  this  operation  by  passing  sutures  of  silkworm  gut  by  means  of 
the  Peaslee  needle.  Although  other  operators  pass  these  sutures 
through  the  cutaneous  margin  (Fig.  106),  the  principle  which  he 
always  observed  in  suturing  was  to  apply  these  interrupted  silkworm- 
gut  sutures  subcutaneously,  the  object  being  to  draw  forward  and  into 
approximation  the  retracted  subcutaneous  structures.  The  needle  Avas 
inserted  into  the  tissues  beneath  the  skin,  carried  under  the  tissues 
to  the  opposite  side,  and  brought  out  just  beneath  the  cutaneous 
margin.  Several  of  these  sutures  were  thus  passed  and  then  tied. 
The  res^ilt  was  a  gaping  margin  from  which  protruded  the  free  ends 
of  the  silkworm  gut. 
Superficial  sutures  I  mm^nm^ 
were  next  passed  be- 
tween the  free  ends 
of  the  deep  tissue  su- 
tures, thus  carefully 
approximating  the 
external  margins  of 
the  wound.  It 
should  have  been 
stated  that  it  was 
Tait's  custom  in 
passing  the  deep  tis- 
sue sutures,  always 
to  make  sure  that  he 
inserted  one  of  them 
in  such  a  position  as 
to  catch  the  re- 
tracted ends  of  the 
sphincter-ani  mus- 
cle, which  Avere  then 
brought  into  appo- 
sition when  the  su- 
tures were  tied.  The 
sutures  were  gener- 
erally  removed  on 
the  seventh  or  eighth 
day,      rarely      later 


Fig.  107. — "Tliui'uds  <il'  tlic  si-liiiR'tcr-aiii  muscle  are  trans- 
fixed by  a  suture  of  strong  catgut."— Keed  (page  270). 


than  the  tenth. 

Modifications. — The  principles  of  flap-splitting  and  of  sphincter  ap- 
proximation first  enunciated  by  Tait  have  been  very  generally  adopted 
by  the  profession.  These  were  the  essential  elements  of  his  teaching. 
Many  of  his  followers  have  changed  the  technique  of  closure  by  the  em- 


270 


A  TEXT-BOOK  OF   GYNECOLOGY 


ployment  of  different  suture  material  and  by  different  methods  of  apply- 
ing the  sutures  themselves.  Eeed  during  the  last  ten  years  has  adopted 
the  following  method  of  applying  the  sutures  in  flap-splitting  opera- 
tions.   The  rectal  flap  of  the  septum  is  caught  at  its  external  corners  by 

a  volsella  and  approxi- 
mated in  the  median 
line,  its  raw  surfaces  be- 
ing brought  together. 
These  are  now  stitched 
together  by  means  of  a 
continuous  catgut  su- 
ture, beginning  above 
and  extending  down  to 
the  anal  margin,  a  step 
which,  for  clearness' 
sake,  is  designedly 
omitted  from  the  illus- 
tration which  shows  this 
operation  in  connection 
with  a  completed  opera- 
tion for  rectocele.  The 
continuous  suture  is 
now  fixed.  The  vaginal 
flap  of  the  septum  is 
next  seized  and  sutured 
in  a  similar  way.  The 
Ijreviously  isolated  ends 
of  the  sphincter  -  ani 
muscle  are  transfixed  by 
a  suture  of  strong  cat- 
gut (Fig.  107)  and  are 
tied  in  the  median  line 
and  the  suture  cut  short 
(Fig.  108).  A  second  suture  of  this  kind  may  be  applied  if  deemed 
expedient.  A  few  rows  of  continuous  catgut  suture  are  now  passed 
from  side  to  side,  one  layer  upon  another  (Fig.  108),  thus  carefully 
approximating  in  an  accurate  tissue-to-tissue  way  the  previously  sepa- 
rated structures  of  the  iDerineum.  The  operation  is  concluded  by  means 
of  an  intercutaneous  suture,  which  may  be  fortified  at  the  discretion 
of  the  operator  with  a  buried  serpentine  suture  of  the  same  material 
(Fig.  109). 

There  are  numerous  other  operations  for  the  repair  of  complete 
laceration  of  the  perineum,  that  have  been  devised  by  able  surgeons, 
adopted  by  many  operators,  and  have  given  satisfactory  results.  Of 
these  the  Simon-Hegar  operation  is  one  of  the  most  important.  It 
consists  in  denuding  the  cicatricial  area  freely,  but,  instead  of  leaving 
a  central  tongue  of  mucous  membrane  in  the  denuded  area,  a  similar 


Fig.  108. — "  A  few  rows  of  continuous  catgut  sutures  are 
now  passed  from  side  to  side." — Eeed. 


THE   PELVIC  FLOOR  AND  ITS   INJURIES 


271 


tongue  is  removed  upward  along  the  dorsum  of  the  vagina.  The  small 
triangular  area  thus  made  in  the  vaginal  mucous  membrane  is  first  ap- 
proximated by  sutures,  after  which  the  remaining  bat  wings  are 
brought  together  and  sutured  by  their  approximated  mucous  margins. 
The  rectal  mucous  surfaces  are  then  sutured  together  by  means  of 
interrupted  sutures,  the  free  ends  of  which  are  left  in  the  rectum.  A 
third  row  of  sutures  is  finally  applied  to  the  cutaneous  surface.  The 
operations  of  Freund,  Hildebrand,  Heppner,  A.  Martin,  and  Le  Fort, 
all  contemplate  denudation  by  cutting  away  the  tissue,  and  closure  by 
the  use  of  interrupted,  nonabsorbable,  sutures.  It  is  not  apparent 
that  any  of  them  are  more  philosophical  in  conception,  more  easily 
done,  or  followed  by  better  results,  than  is  the  flap-splitting  operation 
of  Tait.  In  conclusion,  the  practitioner  may  accept  as  a  safe  working 
method,  the  operation  of  Lawson  Tait  for  complete  laceration  of  the 
perineum,  just  as  he  may 
accept,  as  already  ad-  pSHntfin 
vised,  the  operation  of 
Emmet  for  incomplete 
laceration. 

The  repair  of  deep  in- 
juries of  the  pelvic  floor 
has  engaged  the  serious 
consideration  of  various 
operators.  One  of  the 
principles  most  emphat- 
ically enunciated  by  Em- 
met was  the  necessity  of 
reapproximating  the 
separated  median  fibres 
of  the  levator-ani  muscle. 
It  would  seem,  however, 
that  in  the  case  of  exten- 
sive injuries  to  this  mus- 
cle the  technique  of  the 
Emmet  operation  will 
not  reach  or  control  it, 
and  the  same  may  be  said 
of  those  operations  to 
which  are  attached  the 
names  of  Freund  and  A. 
Martin.  Goldspohn  was 
the  first  to  devise  and 
carry   into   execution   an 

operation  calculated  to  restore  the  integrity  of  the  deep  muscles  of  the 
pelvic  floor  (Medicine,  July,  1897).  In  connection  with  this  operation 
he  laid  it  down  as  an  axiom  that  "  direct  union  of  the  two  lateral  halves 
of  the  muscle  and  edges  of  the  pelvic  fascia  beneath  the  vagina  and 


Fig.  109. — "  The  operation  is  concluded  by  means  of  an 
intercutaneous  suture  which  may  he  fortified  .  .  . 
with  a  buried  serpentine  suture." — Eeed  (page  270). 


272 


A  TEXT-BOOK  OF   GYNECOLOGY 


anterior  to  the  rectum,  should  be  the  miuimum  requirement,  no  matter 
where  the  ruj)ture  showed  itself  superficially  in  the  vagina."  His  opera- 
tion consists  of  an  adaptation  of  the  advanced  views  of  Schatz  and  the 
flap-splitting  principle  of  Tait.  It  is  done  by  dissecting  up  the  lateral 
walls  of  the  vagina,  exposing  the  injured  muscles,  and  restoring  them, 
and  the  associated  fascia,  by  buried  animal  sutures. 

Harris's  Operation. — Harris  has  perfected  the  technique  of  this 
operation    Avhich    he    describes    {Journal    of    the    American    Medical 

Association)  as  fol- 
lows: "When  lacera- 
tion of  the  perineum 
is  present  the  denu- 
dation of  this  part  is 
made  in  the  usual 
manner.  If  this 
body  be  intact,  the 
denudation  is  omit- 
ted. An  incision  is 
then  carried  up  each 
lateral  wall  of  the 
vagina  from  3  to 
5  centimetres.  The 
edge  of  the  muscle 
can  now  usually  be 
felt  and  an  incision 
parallel  therewith  is 
made  through  the 
perivaginal  connec- 
tive tissue,  exposing 
the  muscle  (Fig- 
110),  which  may 
easily  be  dissected 
out  with  the  handle 
of  a  scalpel,  blunt 
dissector,  or  the  fin- 
ger, ventrally  as  far 
as  the  symphysis, 
and  dorsally  until  it 
curves  round  poste- 
rior to  the  rectum. 
Should  the  muscle 
have  been  so  ruptured  and  its  ends  so  retracted  that  its  edge  can 
not  be  distinctly  felt,  the  incision  is  made  along  the  line  which  the 
muscle  sho^dd  occupy,  and  careful  dissection  is  made  for  separated  ends. 
The  ends  of  the  muscle  will  be  found  connected  by  cicatricial  tissue.  I 
have  yet  failed  to  find  the  remains  of  the  muscle  even  when  badly  torn 
and  the  ends  widely  separated. 


Fig.  110.— "The  edge  of  the  muscle  can  now  usually  be  felt 
and  an  incision  parallel  therewith  is  made."— Eeed. 


THE   PELVIC   FLOOR  AND  ITS  INJURIES  273 

"  The  muscle  may  vary  considerably  in  thickness,  and,  when  very 
ihin  and  ribbonlike,  it  may  be  torn  by  a  careless  dissection.  When 
multiple  small  lacerations  are  present,  the  muscle  will  not  be  entirely 
separated  at  any  point,  but  will  be  lengthened,  loose,  and  relaxed.  In 
width  or  distance  laterally,  the  muscle  may  be  dissected  from  3  to  5 
centimetres.  When  it  has  been  well  freed,  forceps  should  be  placed 
on  either  side  of  the  portion  to  be  resected,  so  that  the  ends  when  cut 
shall  not  retract  out  of  reach.  The  portion  resected  should  correspond 
"to  the  point  of  laceration  if  found,  or  when  no  distinct  separation  is 
found,  to  about  the  centre  of  the  muscle.  The  extent  of  the  piece 
resected  will  depend  upon  the  amount  of  separation  or  the  degree  of 
lengthening  and  relaxation.  It  should  be  sufficient  so  that  when  the 
ends  are  drawn  together  the  floor  of  the  pelvis  will  be  restored  to  its 
normal  position  and  degree  of  tension.  The  ends  of  the  muscle  are 
then  sutured  together  with  an  interrupted  or  continuous  catgut  stitch, 
which,  of  course,  remains  buried.  The  opposite  side  is  treated  in  a 
.similar  manner  when  the  incision  of  the  lateral  walls  of  the  vagina 
is  closed  by  a  catgut  suture.  This  latter  suturing  should  be  thoroughly 
done  so  that  no  openings  will  remain  through  which  fluids  or  infection 
may  reach  the  deeper  parts.  When  the  perineum  has  been  torn  this 
is  closed  in  the  usual  way.^' 

Hemorrhage  in  the  course  of  this  operation  is  sometimes  free,  never 
•excessive  and  always  controllable.  It  is,  however,  of  extreme  importance 
that  all  bleeding  points  be  secured  before  the  operation  wound  is  closed, 
as  a  hematoma  will  prevent  union  by  flrst  intention,  and,  by  a  favouring 
infection,  may  defeat  the  objects  of  the  operation. 

The  operation  in  the  hands  of  Harris  has  proved  entirely  satisfac- 
tory. By  its  means  he  restores  the  normal  floor  of  the  pelvis  in  regard 
to  both  tone  and  integrity,  carries  the  vaginal  opening  ventrad  to  its 
normal  position,  and  restores  its  perineal  flexure,  while  the  muscles 
regain  and  retain  their  contractility  and  resume  their  elevating  and 
sphincteric  action  at  the  vaginal  orifice. 


CHAPTEK   XXIII 

MALFORMATIONS   OF   THE  UTERUS 

Classification:  Embryonic,  foetal,  postnatal — Absence — Uterus  unicornis — Foetal, 
infantile  or  pubescent — Uterus  septus — Uterus  bicornis — Uterus  duplex — Minor 
malformations ;  atresia — Treatment ;  stomatoplasty. 

The  malformations  of  the  uterus  are  very  numerous  and  they  are 
among  the  best  known  of  all  the  structural  anomalies  to  which  the 
organs  of  the  body  are  liable.  Further,  their  mode  of  origin  is  in 
most  instances  fairly  well  understood,  a  fact  largely  explicable  by  our 
considerable  knowledge  of  the  embryology  of  the  utero-vaginal  canal. 
They  have  also  a  marked  and  practical  bearing  upon  the  phenomena  of 
the  reproductive  life  of  the  woman,  gynecological  no  less  than  obstet- 
rical. 

Classification. — The  most  recent  and  most  approved  classij&cation 
of  the  malformations  of  the  uterus  is  founded  directly  upon  the  de- 
velopment of  the  organ  (F.  von  Winckel,  Eintheilung  der  Bilchtngshem- 
mungen  der  weiUiclien  Sexualorgane,  1899).  Uterine  development 
may  be  divided  into  two  periods,  an  antenatal  and  a  postnatal;  the 
former  may  again  be  subdivided  into  an  embryonic  and  a  foetal  period. 
The  embryonic  development  of  the  organ  takes  place,  roughly  speaking,, 
in  the  first  three  months  of  intrauterine  life:  it  passes  through  three 
stages,  in  the  first  of  which  there  exist  the  two  Miillerian  ducts  as 
solid  cords  in  the  neighbourhood  of  the  Wolffian  ducts  (first  month); 
in  the  second,  the  ducts  obtain  their  lumen  and  unite  externally 
into  one  utero-vaginal  tube  (second  month);  and  in  the  third,  the 
ducts  fuse  internally  into  one  hollow  tube,  the  utero-vaginal  canal, 
their  upper  parts,  however,  remaining  distinct  as  the  Fallopian  tubes 
(third  and  fourth  months).  The  foetal  development  of  the  uterus  oc- 
curs during  the  remaining  five  or  six  months  of  intrauterine  life,  and 
chiefly  consists  in  the  formation  of  the  fundus  of  the  organ,  the 
transition  from  the  uterus  planifundalis  into  the  nterus  foras  arcuatus,. 
or  foetal  uterus.  Postnatal  development  takes  place  in  two  stages: 
in  the  first,  corresponding  to  the  first  ten  years  of  extra-uterine 
life,  through  the  greater  growth  of  the  body  as  compared  with  that 
of  the  cervix,  the  uterus  fcetalis  becomes  the  uterus  infantilis; 
and  in  the  second,  which  may  be  said  to  extend  from  the  tenth  to 
the  sixteenth  year,  the  infantile  uterus  takes  on  the  characters  of 
274 


MALFORMATIONS  OP  THE   UTERUS 


2Y5 


the  adult  but  virgin  organ.  Now,  the  majority  of  uterine  malforma- 
tions are  simply  stages  of  development  normally  temporary  but  which 
have  become  permanent,  and  they  may  be  divided  into  groups  corre- 
sponding to  the  developmental  stages  which  have  been  enumerated. 
These  groups  may  be  put  in  the  form  of  a  table. 


Periods  of  life.  Groups. 

I.  (a)  Absence  of  uterus,  complete,  together  with  absence  of 

tubes  and  vagina  (very  rare). 

(b)  One-horned  uterus,   with  no  trace  of   the  other  horn 

(uterus  unicornis  sine  ullo  rudimento  cornu  alterius). 

II.  (a)  Externally  double  uterus  {uterus  duplex  sine  didelphys  ; 

uterus  hicornis). 

(b)  Solid  or  partly  excavated  uterus  {uterus  solidus,  uterus 
Embryonic -{  rudi7nentarius,  itterus  partim  excavatus). 

(c)  Combination  of  (a)  and  (b)  {uterus  duplex  solidus,  uterus 
bicornis  rudimentarius). 

(d)  One-horned  uterus,  witli  other  horn  solid  or  partly  exca- 
vated {uterus  unicornis  ctim  rudimento  cornu  alterius). 

III.  Uterus  divided  internally  more  or  less  completely,  without 
or  with   external  signs  of  duplicity  {litems  septus, 
subseptus,  uterus  bicornis  septiis). 
f  IV.  Uterus  with  flat  fundus,  with  or  without  complete  or  par- 
tial internal  duplicity  {uterus  planifundalis  septus, 
subseptus,  simplex). 
V.  Uterus  with  fcetal  characters  (small  body,  large  cervix). 
Postnatal VI.  Uterus  with  infantile  characters  {uterus  infantilis). 


Foetal 


There  are  some  malformations  which  do  not  find  a  place  in  this 
scheme  of  classification.  One  of  them,  the  trifid  uterus  or  uterus 
accessorius,  is  specially  difficult  of  embryonic  explanation.  To  account 
for  it  we  have  to  suppose  the  existence  of  a  double  Mlillerian  duct 
on  one  side;  possibly  it  arises  in  the  pre-embryonic  or  germinal  period. 
Congenital  prolapsus  uteri  also,  which  may  be  grouped  with  the  mal- 
formations, does  not  represent  a  stage  in  the  development  of  the 
organ  so  far  as  is  known;  since,  however,  it  has  always  been  found 
associated  with  spina  bifida,  it  may  be  really  rather  a  concomitant 
anomaly  of  spinal  arrested  development  than  an  arrest  in  the  evolu- 
tion of  the  uterus.  As  to  the  cause  of  these  arrests  in  iiterine  de- 
velopment there  is  still  much  darkness:  inflammatory  processes,  e.  g., 
foetal  peritonitis;  defective  formation  of  the  abdominal  walls,  e.  g., 
umbilical  hernia;  the  presence  of  tumour  germs  preventing  union  of 
the  Miillerian  ducts,  and  traction  upon  these  ducts  exercised  by  neigh- 
bouring structures,  have  all  been  adduced  as  possible  teratogenic  fac- 
tors; but  they  are  all  insufficient  to  explain  the  anomalies  which  have 
arisen  in  the  embryonic  period  of  intrauterine  life.  It  will  probably  be 
found  that  uterine  malformations,  like  malformations  and  monstrosities 
of  other  parts  of  the  body,  are  due  to  the  action  of  germs,  toxines,  and 
poisons,  upon  the  tissues  in  the  course  of  evolution  (Pathology  of  the 


276  ^  TEXT-BOOK   OF   GYNECOLOGY 

Embryo.)  (Scottish  Medical  and  Surgical  Journal,  v,  481,  1899).  It  is 
unnecessary  in  a  work  sucli  as  this  to  describe  in  detail  all  the  varieties 
and  snbvarieties  of  uterine  malformation  which  the  pathologist  has 
differentiated;  it  will  be  sufficient  if  the  leading  types  are  dealt  with 
in  outline. 

Absence  or  Rudimentary  State  of  the  Uterus. — Complete  absence  of 
the  uterus,  save  in  sympodial  foetuses  and  the  acardiac  twin  monstros- 
ity, is  of  excessive  rarity;  indeed,  it  is  doubtful  whether  its  occurrence 
in  the  adult  woman  has  been  established.  On  the  other  hand,  it  is 
far  from  uncommon  to  meet  with  patients  in  whom  the  organ  is 
physiologically  absent,  or,  to  put  it  in  other  words,  in  whom  there  is  a 
rudimentary  uterus  {solidus,  partim  excavatus,  memhranaceus).  The 
tubes  and  vagina  are  usually  also  defective  in  such  cases,  but  it  is 
common  to  find  a  well-formed  vulva  and  even  a  short  vestibular  vagina 
which  has  been  made  deeper  by  attempts  at  coitus.  The  symptoms 
vary  with  the  presence  or  absence  (or  at  least  physiological  absence) 
of  the  ovaries.  There  is  always  necessarily  amenorrhoea;  but  when 
there  are  functionating  ovaries  menstrual  molimina  are  met  with,  there 
are  occasionally  vicarious  hemorrhages,  and  there  may  be  a  great  deal 
of  pelvic  pain.  Secondary  sexual  characters  are  generally  present,  but 
the  vulvar  hair  may  be  defective.  By  means  of  a  recto-abdominal 
bimanual  examination  (under  an  anassthetic  if  necessary),  and  with 
the  help  of  a  sound  in  the  bladder,  it  can  usually  be  made  out  that 
the  uterus  is  seriously  defective.  In  the  marked  cases  no  thickness  of 
tissue  can  be  felt  between  the  rectum  behind  and  the  bladder  in  front. 
It  is  doubtful  in  these  instances  whether  any  treatment  of  the  nature 
of  ferruginous  tonics  and  the  like  should  be  adopted,  for  such  will 
only  prove  inefPective  and  disappointing  to  the  patient.  When  severe 
monthly  suffering  exists,  the  opening  of  the  abdomen  and  the  removal 
of  the  functionating  ovaries  must  be  considered;  indeed,  it  is  demanded 
in  many  instances,  and  can  be  done  with  not  more  than  the  ordinary 
risks  of  a  cceliotomy.  Vineberg  [Transactions  of  the  American  Gyneco- 
logical Society,  xxiii,  396,  1898)  has  recently  reported  a  case  of  this 
kind  in  which  the  removal  of  the  ovaries  was  followed  by  the  disappear- 
ance of  symptoms;  during  the  laparotomy  it  was  noted  that  in  addition 
to  the  ovaries  there  were  two  small  oval  bodies  lying  at  the  pelvic  brim 
which  were  probably  rudimentary  uterine  cornua. 

Uterus  Unicornis. — The  absence  of  rudimentary  development  of 
one  horn  of  the  uterus  produces  the  unicornate  variety;  when  there 
is  a  rudimentary  horn  it  may  either  be  solid  or  show  a  cavity,  and 
under  the  latter  circumstances  pregnancy  or  menstrual  retention  may 
occur  in  that  cavity.  The  one-horned  uterus  has  no  proper  fundus, 
for  it  inclines  to  one  side  and  tapers  to  a  point  where  it  becomes  con- 
tinuous with  the  Fallopian  tube  (only  one  tube  is  usually  present). 
Concomitant  malformations  are:  small  vagina,  vagina  septa,  absence 
of  one  kidney  and  ureter,  rudimentary  condition  of  the  ovaries.  The 
uterus  unicornis  is  not  often  diagnosticated  during  life  unless  it  is  dis- 


MALFORMATIONS  OF   THE   UTERUS  277 

covered  during  a  laparotomy.  Menstruation  is  not  necessarily  afEected 
and  pregnancy  may  occur  in  the  single  well-developed  horn  and  pass 
to  a  normal  termination;  but  when  there  is  gestation  in  the  rudi- 
mentary horn,  then  rupture  of  the  sac  commonly  happens  with  results 
practically  undistinguishable  from  those  found  after  the  bursting  of 
a  tubal  pregnancy. 

Foetal  and  Infantile  or  Pubescent  Uterus. — When  the  uterus  in  the 
adult  woman  instead  of  taking  on  its  full  development  retains  its 
foetal  or  infantile  characters,  it  is  common  to  find  along  with  it  a 
poor  mammary  and  vaginal  development  with  symptoms  of  defective 
ovarian  formation  and  sometimes  such  systemic  disorders  as  chlorosis. 
There  is  either  amenorrhoea  or  a  scanty  flow;  sterility  is  met  with;  and 
there  may  be  also  dysmenorrhoea.  The  vaginal  and  -bimanual  exami- 
nations, together  with  the  introduction  of  the  sound,  should  enable 
a  diagnosis  to  be  formulated,  and  the  relation  of  the  size  of  the  body 
of  the  organ  to  that  of  the  cervix  will  distinguish  the  foetal  from  the 
infantile  type.  The  treatment  will  be  directed  toward  establishing  the 
growth  of  the  uterus,  and  this  is  far  from  hopeless  in  the  infantile  form. 
Marriage  has  sometimes  a  good  effect  but  should  not  be  recommended 
unless  the  menstrual  function  has  been  established.  In  the  unmarried, 
reliance  must  be  jDlaced  upon  the  administration  of  iron,  arsenic,  and 
quinine,  together  with  nourishing  food  and  gymnastic  exercises;  in  the 
married,  electrical  stimulation  of  the  uterus  or  simply  the  periodical 
passing  of  the  sound  may  be  employed,  but  the  insertion  of  a  stem 
pessary  as  recommended  by  many  is  not  free  from  risk  and  is  of 
doubtful  efficacy. 

Uterus  Septus. — The  least  marked  form  of  double  uterus  is  the 
septate  variety  in  which  the  only  indication  of  duplicity  is  found  in 
the  division  of  the  interior  more  or  less  completely  into  two  cavities 
(uterus  septus,  suhseptus).  Externally  the  uterus  appears  to  be  single 
but  has  sometimes  a  more  markedly  globular  outline  than  is  usual. 
The  two  cavities  are  commonly  situated  laterally,  and  there  may  or 
may  not  be  indications  of  duplicity  in  the  cervix.  The  clinical  symp- 
toms are  indefinite:  there  may  be  amenorrhoea  and  dysmenorrhoea;  or 
there  may  occur  the  curious  twice  monthly  recurring  hemorrhage  which 
may  be  supposed  to  be  menstruation  from  the  two  cavities  of  a  non- 
synchronous  type;  and  if  one  of  these  discharges  is  small  in  amount 
and  acconijoanied  by  pain  we  have  an  explanation  of  one  variety  of  the 
midpain  or  "  Mittelschmerz."  It  is  possible  that  a  septate  uterus  may 
be  a  cause  of  habitual  abortion,  at  any  rate  in  one  case  the  division 
of  the  uterine  septum  was  followed  by  a  normal  pregnancy.  During 
curettage  the  curette  has  been  known  to  pass  from  one  cavity  of  a 
septate  uterus  into  the  other,  giving  the  sensation  of  perforation  of 
the  organ  (Blondel,  Bulletins  et  mem/dres  de  la  Societe  ohstetrique  et  gyne- 
cohgique  de  Paris,  p.  53,  1898).  The  presence  of  the  septum  may 
complicate  labour  in  this  form  of  malformation;  it  may  cause  a  mal- 
presentation  or  a  low  implantation  of  the  placenta,  or  to  it  the  pla- 


278  ^  TEXT-BOOK  OF  GYNECOLOGY 

centa  may  be  attached,  in  which  case  hemorrhage  in  the  third  stage 
is  to  be  looked  for.  The  diagnosis  of  this  malformation  has  usually 
been  made  accidentally  during  the  extraction  of  the  placenta  or  in 
turning. 

Uterus  Bicornis. — In  the  bicornate  uterus  the  upper  part  of  the 
body  shows  distinct  duplicity  but  the  lower  part  and  the  cervix  are 
single;  on  internal  examination  it  may  be  found  that  the  duplicity 
extends  to  the  cervical  canal  also.  The  degree  of  separation  of  the 
two  horns-  varies  within  wide  limits,  from  a  simple  notch  on  the 
fundus  to  a  wide  interval.  Further,  the  horns  may  be  of  the  same  or 
of  different  size,  and  in  the  interval  between  them  may  be  seen  a  band 
stretching  from  rectum  to  bladder  (recto-vesical  ligament).  The  ex- 
ternal genitals  are  generally  normal  but  the  vagina  may  show  different 
degrees  of  duplicity  (vagina  septa,  subsepta).  One  of  the  horns  may  be 
solid  or  partly  imperforate,  and  in  the  latter  case  it  may  become  the 
seat  of  a  pregnancy  or  a  menstrual  blood  accumulation  (hematometra). 
The  clinical  history  will  be  very  similar  to  that  met  with  in  the  septate 
variety.  As  regards  menstruation,  there  may  be  a  simultaneous  dis- 
charge from  both  cavities  each  month,  or  a  flow  from  one  cavity  one 
month  and  from  the  other  the  following  month,  or  a  discharge  from 
each  cavity  each  month  but  not  at  the  same  time  (fortnightly  variety). 
Pregnancy,  apparently,  not  uncommonly  happens  in  the  bicornate 
uterus:  during  it,  hemorrhage  may  go  on  from  the  unoccupied  horn  or  a 
decidual  membrane  may  form  in  it;  both  horns  may  contain  impreg- 
nated ova,  and  the  age  of  the  gestation  may  not  be  the  same  in 
each,  thus  explaining  some  of  the  anomalous  cases  of  superfoetation; 
and,  rarely,  a  twin  conception  may  occur  in  one  horn.  Labour  may 
be  interfered  with  in  various  ways:  there  may  be  a  malpresentation; 
there  may  be  delay  from  the  presence  of  the  recto-vesical  band;  there 
may  be  a  low  implantation  of  the  afterbirth;  and,  as  Halban  (Archiv 
fur  Gynakologie,  lix,  188,  1899)  has  lately  shown,  in  cases  where  the 
pregnant  horn  lies  obliquely  to  the  empty  one  the  head  of  the  infant 
may  be  driven  during  labour  through  the  septum  between  the  two 
cavities,  and  Avhat  was  a  left-sided  foetus  may  be  expelled  through  the 
right  cervical  orifice.  The  diagnosis  of  the  uterus  bicornis,  like  that 
of  the  septate  organ,  is  often  not  made  till  labour  supervenes  or 
till  the  abdomen  is  opened  for  some  purpose;  but  if  a  double  vagina 
or  a  double  os  uteri  exists  the  anomaly  may  be  suspected*  and  then 
a  careful  examination  bimanually  and  with  two  uterine  sounds  may 
suffice  to  make  it  plain. 

Uterus  Duplex. — The  most  complete  form  of  double  uterus  is  the 
uterus  duplex,  separatus  or  didelphys;  in  it,  the  Miillerian  ducts  have 
failed  to  unite  in  that  part  of  them  which  goes  to  form  the  body  and 
cervix  of  the  uterus,  and  commonly  also  in  the  vaginal  part,  so  that 
there  is  at  the  same  time  a  vagina  septa.  It  is  much  rarer  than  the 
uterus  bicornis  and  it  is  impossible  to  distinguish  the  one  from  the 
other   with    certainty    during   life.      In    a    case    reported   by   Ameiss 


MALFORMATIONS   OP  THE   UTERUS 


2T9 


Fig.   111. 


'  A  bicornate  uterus  with   each   horn  well 
developed." — Eeed  (page  281). 


{American  Journal  of  Ob- 
stetrics, xxxiii,  693,  1896) 
both  uteri  were  some- 
what retro  verted;  and  in 
one  put  on  record  by 
Bernhard  {CentralUatt 
fiir  Gy7idkologie,xxi,14:64:, 
1897)  botli  were  icetal  in 
development;  in  Ameiss's 
case  there  was  pregnancy 
and  in  Bernhard's  ster- 
ility. 

Minor  Malformations. 
— The  uterus,  in  addi- 
tion to  the  typical  and 
marked  malformations  which  have  been  already  described,  may  be  the 
subject  of  smaller  anomalies,  such  as  the  want  of  rounding  of  the  fundus 
(uterus  plaiiifundalis) ,   imperf oration   of   the    cervical    canal,   or   the 

presence  of  a  diaphragm 
in  it.  Congenital  pro- 
lapsus uteri  has  been  re- 
corded (Ballant3riie  and 
Thomson,  American 
Journal  of  Obstetrics, 
XXXV,  161,  1897);  curi- 
ously enough  in  all  the 
reported  instances  it 
has  been  met  with  in 
infants  suffering  from 
lumbo  -  sacral  spina  bi- 
fida. In  one  sense 
pathologic  anteflexion 
and  retroflexion  of 
the  uterus  may  be  re- 
garded as  malforma- 
tions; but  they  are  con- 
sidered elsewhere.  Con- 
genital elongation  of  the 
cervix  or  conical  cervix 
also  occurs. 

Atresia,  or  complete 
occlusion  of  the  cervical 
canal,  resulting  in  reten- 
tion   of    the    menstrual 

Fig.  112.-"  This  secretion...  often  accumulates  to  a        ^^^'^^    ^^    sometimes    en- 
degree  that  results  in  dilatation  of  the  cervical  canal."        countered.       Among    the 

— Eeei)  (page  282).  minor  malformations  of 


280 


A  TEXT-BOOK  OF  GYNECOLOGY 


the  uterus  may  be  mentioned  stenosis,  by  which  is  meant  a  narrowing 
of  the  calibre  of  the  canal^  the  constriction  being  situated  as  a  rule 
either  at  the  external  os  or  the  internal  os,  or,  it  may  include  the 
entire  canal. 

The  treatment  of  malformations  of  the  uterus  must,  of  course,  vary 
according  to  the  condition.  In  those  cases  in  which  the  uterus  is 
absent  or  extremely  rudimentary,  but  in  which  there  develops  a  men- 
strual molimen,  the  patient  may  be  seriously  afflicted  with  ineffectual 
efforts  at  menstruation.  Profound  neurotic  disturbances  are  liable  to 
ensue.  In  these  cases  the  only  relief  lies  in  extirpation  of  the  rudi- 
mentary ovaries.  In  those  cases  in  which  the  uterus  is  foetal,  infantile, 
or  pubescent,  the  degree  of  development  encoun- 
tered will  determine  the  remedial  course  to  be 
employed.  If  the  uterus  is  less  than  an  inch  and 
three  quarters  in  longitudinal  diameter,  any  effort 
to  force  its  development  by  local  means  will  prob- 
ably prove  unavailing;  or,  if  development  is  pro- 
voked, there  is  but  little  hope  that  it  can  be  car- 
ried beyond  that  degree  which  will  result  only  in 
the  most  unsatisfactory  establishment  of  the  men- 
strual function.  If,,  however,  the  uterus  is  an 
inch  and  three  quarters  or  more  in  depth,  intra- 
uterine faradization  may  be  employed  with  some 
prospect  of  success.  Massage  of  the  uterus  is  like- 
wise an  expedient  calculated  to  promote  its- 
growth.  But  little,  however,  is  to  be  promised  in 
these  cases.  Patients  or  their  friends  may  be 
assured  that  in  certain  instances  the  uterus  has 
suddenly  developed  after  having  remained  more 
or  less  rudimentary  for  years.  These  may  be 
called  instances  of  delayed  development.  A  nor- 
mal exercise  of  the  menstrual  function  is  never 
to  be  promised  in  these  cases,  nor  is  pregnancy  to 
be  held  up  as  either  possible  or  desirable.  It  is 
frequently  to  be  noticed  that  girls  with  pubescent 
uteri  and  corresponding  deficiency  of  the  menstrual  function  show 
a  tendency  to  obesity.  These  phenomena  can  only  be  accepted 
as  exemplifications  of  the  biologic  laAV  of  antagonism  between  growth 
and  genesis.  The  indication  for  treatment  in  these  cases  is  to 
reduce  the  flesh  and  improve  the  quality  of  the  blood  which  will 
generally  be  found  to  be  deteriorated  in  some  particular.  When 
the  flesh  is  reduced  to  the  normal  standard  and  the  normal  bal- 
ance of  the  nutrient  functions  is  thereby  properly  established, 
the  uterus  sometimes  shows  a  disposition  to  develop  without  local 
treatment.  The  latter,  however,  is  important  and  should  not  be 
omitted.  The  bicornate  or  septate  uterus  may  be  capable  of  exer- 
cising a  menstrual  function  in  either  of  its  compartments.     In  occa- 


Fig.  113.— "It  is  often 
necessary  to  remove 
a  segment  of  tissue 
from  either  the  an- 
terior or  posterior  lip 
of  the  cervix."  — 
Eeed  (page  283). 


MALFORMATIONS  OF  THE   UTERUS 


281 


sional  instances  one  cavity,  and  still  more  rarely  both,  is  closed,  with 
resulting  hematometra.  The  condition  may  be  undetected  for  some 
time,  for  the  reason  that  the  menstrual  discharge  may  regularly  appear 
from  one  side  of  the  uterus,  while  it  is  retained  in  the  other  side.  The 
latter  condition,  however,  sooner  or  later  develops  pain  which  calls  for 
intervention,  when  the  real  condition  of  the  uterus  is  for  the  first  time 
discovered.  The  appearance  presented  in  the  examination  is  some- 
times bewildering  in  view  of  the  fact  that  the  gradual  accumulation  of 
fluid  may  have  forced  a  comparatively  thin  and  elastic  septum  down- 
ward through  the  exter- 
nal OS,  whence  it  pro- 
trudes in  the  form  of  a 
cyst.  In  these  cases  a 
mere  excision  of  the  wall 
will  result  in  the  collapse 
of  the  cystlike  accumula- 
tion. Cullingworth  has 
reported  (Transactions 
of  the  American  Gyneco- 
logical Society)  an  inter- 
esting case  which  pre- 
sented all  the  symptoms 
of  a  suppurating  cyst 
outside  the  uterine  cav- 
ity, with  a  fistulous  com- 
munication between  it 
and  some  part  of  the 
uterine  canal.  Explora- 
tion by  abdominal  inci- 
sion revealed  a  bicornate 
uterus  with  each  horn 
well  developed,  the  right 
being  larger,  more 
globular  in  shape,  and 
situated  farther  back  in 
the  pelvis,  than  the  left. 
The  two  horns  con- 
verged toward  an  isth- 
mus and  were  continued  in  a  common  cervix.  A  retroperitoneal  mass 
on  the  right  of  the  cervix  was  found  to  be  the  origin  of  the  discharge 
and  was  removed  by  vaginal  section.  It  proved  to  be  the  expanded 
right  half  of  the  cervix  (Fig.  111). 

Stenosis  may  be  relieved  by  an  operation  which  Dolageniere  (CTii- 
rurgie  de  Vuterus)  appropriately  designates  as  stomatoplasty,  which  has 
for  its  object  the  permanent  dilatation  of  the  cervical  orifice.  Various 
cxpoflicnts  have  been  devised  for  this  purpose.  Courty  before  1880 
and  Kiister  in  1885  promulgated  the  idea  of  discission  of  the  neck 


Fig.  114. — "Cases  where  there  has  been  long  distention 
with  menstrual  fluid." — Keed  (page  283). 


282 


A  TEXT-BOOK  OF   GYNECOLOGY 


with  reference  to  a  permanent  enlargement  of  the  external  os.  Dela- 
geniere  {Cliirurgie  de  I'uterus,  p.  328)  has  investigated  the  literature 
of  the  subject,  and  finds  that  the  examples  of  Courty  and  Kiister  have 
been  followed  by  Dudley,  Nourse,  Keed,  and  Pozzi;  although  the 
object  aimed  at  by  these  different  operators  has  been  somewhat  differ- 
ent. The  procedure  of  Kiister,  like  that  of  Dudley,  was  designed 
simply  to  enlarge  the  otherwise  straight  uterine  canal  which  terminated 
in  a  contracted  os;    while  the  operations  of  Dudley  and  Reed  were 

designed  more  especially 
to  straighten  the  tortuous 
canal  in  cases  of  ante- 
flexion. 

Enlargement  of  the 
external  os  is  indicated  in 
all  cases  of  either  occlu- 
sion or  narrowing  of  that 
orifice.  The  same  may  be 
said  of  those  cases  of  con- 
genital atresia  that  are  oc- 
casionally noted.  In  both 
cases  the  cause  may  arise 
from  narrowing,  either 
congenital,  or  due  to  a 
cicatricial  deposit  follow- 
ing the  application  of 
strong  caustics  or  the  ex- 
cessive narrowing  of  the 
canal  by  trachelorrhaphy. 
One  of  the  first  of 
these  sequent  conditions 
is  the  retention  of  the 
normal  cervical  secretion. 
This  secretion,  albumin- 
ous in  character,  often 
accumulates  to  a  degree 
that  results  in  dilatation 
of  the  cervical  canal  (Fig. 
112).  In  this  state  the  re- 
tained secretion  forms  a 
mucous  plug  which  entirely  occludes  the  lower  end  of  the  uterine  tract. 
Such  a  condition  persisting  through  months  or  even  years  results  sooner 
or  later  in  hypertrophy  of  that  organ;  not  only  is  the  uterus  enlarged, 
but  hypertrophic;  endometritis  is  developed.  Dysmenorrhoea  of  the 
obstructive  variety  is  an  ordinary  result.  The  endometrial  changes 
may  go  to  the  point  of  fungous  degeneration  in  which  case  monorrhagia 
and  metrorrhagia  are  the  consequences.  In  the  absence  of  the  fore- 
going indications,  or,  for  that  matter,  in  cases  in  which  they  are  pres- 


FiG.  115. — "There  exists  a  redundant  endometrium 
which  may  demand  subsequent  curettement." — 
Keed  (page  283). 


MALFORMATIONS  OP  THE  UTERUS  283 

ent,  sterility  is  the  condition  which  brings  the  patient  to  the  doctor's 
office.  The  obstruction  to  conception  which  is  afforded,  mechanically, 
not  only  by  the  narrowed  orifice  of  the  uterus,  but  by  the  constant  plug 
of  mucus  within  the  cervical  canal,  are  the  conditions  that  demand 
removal. 

The  operation  may  be  performed  by  different  methods.  In  cases  in 
which  the  os  is  of  the  pin-hole  variety,  very  narrow  and  with  a  very 
considerable  amount  of  retained  cervical  secretion  above  it,  the  cervical 
margins  will  be  found  to  be  little  else  than  a  film  of  tissue  which  is 
easily  broken  down  by  a  dilator,  or  may  be  successfully  broken  up  by 
means  of  a  stellate  incision.  This  is  sometimes  all  the  operation  that 
is  necessary;  in  the  majority  of  cases,  however,  it  will  not  be  found  to 
be  sufficient.  It  is  often  necessary  to  remove  a  segment  of  tissue  from 
either  the  anterior  or  posterior  lip  of  the  cervix  (Fig.  113)  and  to  bring 
the  mucous  membrane  out,  stitching  its  margin  fast  to  the  denuded 
margin  of  the  other  lip  of  the  incision.  If  this  is  done  anteriorly 
and  posteriorly,  a  slight  bilateral  incision  having  been  previously  made, 
a  very  slight  ectropion  is  produced.  The  results  of  the  operation  are 
very  generally  satisfactory.  It  should  be  remembered,  however,  that 
in  cases  where  there  has  been  long  distention  with  menstrual  fluid 
(Fig.  114)  there  exists  a  redundant  endometrium  (Fig.  115)  which  may 
demand  subsequent  curettement. 

Congenital  elongation  of  the  cervix  or  conical  cervix  may  be  treated 
by  forcible  dilatation;  if  this  is  not  satisfactory  the  cervix  should  be 
amputated.     (See  Amputation  of  Cervix.) 


CHAPTEE    XXIV 
DISPLACEMENTS   OF   THE   UTERUS 

Normal  position  of  the  uterus — Displacements  in  general :  Varieties,  causes,  pathol- 
ogy, treatment  —  Retro-deviations:  Symptoms  and  diagnosis  —  Treatment: 
Massage,  electrolysis,  tamponade,  pessaries,  surgical  —  Shortening  the  rovmd 
ligaments — Alexander's  operation — Mann's  operation — GofEe's  operation — By- 
ford's  operation — Vaginal  iixation:  The  fundus,  the  cervix — Pryor's  opera- 
tion— Ventral  fixation — direct,  indirect — Anterior  abdominal  cuneo-hysterec- 
tomy  —  Ante-deviations:  Symptoms,  pathology,  treatment  —  Dilatation  and 
curetting — Dudley's  operation — Prolapsus:  Etiology,  jjathology,  symptoms — 
Treatment:  Conservative,  surgical — Emmet's  operation  (anterior  colporrhaphy) 
— Inversion:  Symptoms,  prognosis,  pathology,  treatment. 

The  normal  position  of  the  uterus  can  not  be  indicated  by  definite 
lines  or  specific  limitations.  By  the  nature  of  its  construction  and  in 
consequence  of  its  visceral  relations,  it  has  a  considerable  range  of 
mobility.  In  infantile  life  its  long  axis  presents  but  slight  deviation 
from  the  long  axis  of  the  body,  while  its  locus  is  on  a  line  with  the 
pelvic  inlet.  In  mature  life,  however,  the  fundus  leans  forward  to 
such  a  degree  that  the  long  axis  of  the  uterus  lies  at  right  angles  with 
the  brim  of  the  pelvis,  the  change  of  position  amounting  to  about  45°. 
There  occurs  at  this  time  a  normal  recession  of  the  organ,  until  its 
fundus  lies  a  little  below  a  line  drawn  from  the  top  of  the  symphysis 
pubis  to  the  promontory  of  the  sacrum.  The  distance  from  this  line 
to  the  coccyx  is  about  five  inches,  one  half  of  which  distance  is  occu- 
pied by  the  uterus  in  its  long  axis.  While  this  definition  of  the  posi- 
tion of  the  uterus  is  as  nearly  correct  as  can  well  be  stated  in  words, 
the  fact  should  be  remembered  that  this  organ  vacillates  both  in  actual 
location  and  relative  position.  A  loaded  rectum  or  sigmoid  may  force 
it  forward,  while,  in  the  presence  of  an  empty  bowel  and  a  distended 
bladder,  the  fundus  of  the  uterus  is  lifted  upward  and  backward.  The 
uterus  being  swung  in  the  pelvis  by  attachments  upon  either  side,  the 
focal  points  of  which  are  situated  laterally  in  the  middle  segment,  it 
follows  that  when  the  fundus  is  moved  in  one  direction,  the  cervix 
must  move  in  the  opposite  direction.  Aside  from  these  movements 
the  uterus  has  to  a  certain  extent  an  up-and-down  movement,  rhyth- 
mical with  the  respiratory  movements  of  the  abdomino-thoracic  dia- 
phragm. It  is  this  movement  of  the  uterus,  observable  in  almost  any 
patient  upon  the  examination  table,  that  renders  it  more  appropriate 
to  designate  as  the  pelvic  diaphragm  the  structures  in  which  the  uterus 
284 


DISPLACEMENTS   OP   THE   UTERUS  285 

is  embedded;,  rather  than  to  apply  that  term  to  the  deep  muscular  layer 
of  the  pelvic  floor.  These  movements  are  normal,  and  any  change  of 
position  within  this  normal  range  of  activity  should  not  be  construed 
as  a  departure  from  the  healthy  standard.  The  arc  of  mobility  may 
vary  from  45°  to  90°,  while,  with  the  rectum  and  bladder  empty  and 
with  no  undue  voluntary  pressure  from  above,  the  uterus  will  be  found 
to  return  to  a  position  approximating  that  already  defined.  A  uterus 
may  be  said  to  be  displaced  when  it  ceases  to  manifest  these  normal 
variations  of  position,  and  when  it  persistently  remains  in  a  position 
distinctly  at  variance  with  the  one  which  it  should  occupy  under 
average  conditions. 

A  proper  comprehension  of  uterine  displacements  presupposes  an 
understanding  of  the  anatomic  connections  and  jjhysical  forces  by  which 
the  womb  is  retained  in  position  in  a  state  of  health.  It  is  important, 
at  the  outset,  to  look  upon  the  uterus  as  a  susjDended  rather  than  as  a 
supported  organ.  The  suspensory  apparatus  consists  of  (a)  the  peri- 
toneal duplication  called  the  broad  ligaments,  (b)  the  round  ligaments, 
(c)  the  utero-sacral  ligaments,  (d)  its  attachments  to  the  bladder  and 
(e)  to  the  structure  comprising  the  floor  of  the  cul-de-sac  of  Douglas, 
while  (/)  the  cellular  tissue  at  either  side  of  the  uterus  is  not  to  be 
ignored.  The  idea  that  the  uterus  is  supported  by  a  column  from  be- 
low was  long  ago  demonstrated  as  fallacious  by  Emmet.  A  moment's 
reflection  upon  the  infrauterine  structures  will  convince  the  reader 
that  they  are  neither  constituted  nor  arranged  to  furnish  support  to 
the  uterus;  on  the  contrary,  so  far  as  they  tend  to  exercise  a  modifying 
influence  upon  that  organ  at  all  it  is  to  draw  it  farther  down  in  the 
pelvis,  rather  than  to  maintain  it  at  its  normal  level.  It  is  to  be 
recognised,  however,  that  the  vagina,  the  lower  segment  of  the  rectum, 
and  the  lower  third  of  the  bladder,  are  kept  from  exercising  undue  and 
overpowering  traction  upon  the  uterus  and  its  suspensory  apparatus 
by  virtue  of  the  supporting  influence  of  the  pelvic  floor  when  in  a 
state  of  integrity. 

The  varieties  of  uterine  displacement  may,  in  fact,  be  as  numerous 
as  are  the  variations  from  its  average  normal  position.  For  con- 
venience of  study,  however,  these  deviations  are  classified  with  refer- 
ence to  the  abnormal  movement  of  the  fundus  anteriorly,  posteriorly, 
or  laterally,  and  with  reference  to  the  movement  of  the  entire  organ 
either  upward  or  downward.  As  a  result,  we  shall  have  occasion  to 
consider  in  the  order  of  their  frequency  and  relative  importance  (a) 
retro-deviations,  (h)  ante-deviations,  (c)  prolapsus,  (d)  lateral  deviations, 
and  (e)  inversion.  The  ante-  and  the  retro-deviations  are  further  divided 
into  versions  and  fiexions.  A  uterus  is  said  to  be  in  a  condition  of  ver- 
sion when  its  longitudinal  axis  deviates  from  its  normal  plane;  while 
flexion  of  the  uterus  consists  in  the  bending  of  the  organ  upon  itself. 

The  causes  of  uterine  displacements  are  numerous,  and  are  to  be 
considered  in  their  relation  to  abnormal  deviations  in  general,  rather 
than  with  reference  to  the  operation  of  a  particular  cause  in  producing 


286  A  TEXT-BOOK  OP  GYNECOLOGY 

a  particular  displacement.  Thus,  constipation,  by  inducing  pressure 
upon  the  uterus  through  the  direct  influence  of  either  a  loaded  rectum 
or  sigmoid,  or  by  the  pressure  of  the  enteroptosis  that  constipation 
sometimes  causes,  forces  the  uterus  downward  in  the  pelvis.  Whether 
the  pressure  thus  exercised  exaggerates  the  pre-existing  normal  ante- 
version,  or  whether  it  forces  the  uterus  backward  into  a  distinct  retro- 
deviation, depends  upon  the  incidence  of  co-operative  forces.  This  is 
illustrated  by  the  downward  pressure  exercised  as  above  indicated  at 
the  same  time  that  the  uterus  is  forced  backward  by  a  distended  blad- 
der, a  combination  of  influences  calculated  to  produce  retro-deviation; 
or  the  same  condition  may  be  induced  by  having  the  uterus  lifted  up 
by  means  of  a  distended  bladder  when  the  patient  receives  a  sudden 
fall  or  jumps  from  a  vehicle,  landing  upon  her  heels,  thus  forcing  the 
fundus  suddenly  below  the  promontory  and  into  the  excavation  of  the 
pelvis.  Child-bearing  is,  perhaps,  the  most  fruitful  single  cause  of 
uterine  displacements.  In  the  parturient  act,  the  uterus  is  subjected 
to  violent  influences  which  may  damage  its  suspensory  apparatus.  If 
the  lying-in  woman  gets  up  before  the  womb  has  had  time  to  shrink, 
or  if  she  engages  in  laborious  occupation  while  it  is  yet  heavy,  she  is 
very  liable  to  have  some  form  of  uterine  displacement  as  a  result.  In 
many  cases,  even  after  the  lapse  of  considerable  time,  a  remaining  sub- 
involution makes  the  uterus  so  heavy  that  it  is  thereby  forced  out  of 
its  normal  poise.  Occupation,  particularly  those  employments  that 
involve  the  lifting  or  carrying  of  heavy  burdens,  or  that  necessitate 
overhead  work  or  much  stair-climbing  (see  General  Etiology),  tend  to 
force  the  womb  out  of  position.  Malpositions  of  the  uterus  are  very 
common  among  young  women  employed  in  shops  and  factories,  where 
long  hours  of  standing  are  necessary.  Pelvic  inflammations,  particu- 
larly cases  of  metritis  of  puerperal  origin  and  of  Fallopian  tube  in- 
fection, resulting  in  pelvic  exudations  and  consequent  adhesions,  are  a 
fruitful  source  of  displacements. 

The  pathology  of  uterine  displacements  has  been  foreshadowed  to 
a  certain  extent  in  the  etiology.  The  changes  that  ensue  on  the  first 
departure  of  a  permanent  character  from  the  normal  poise  of  the  uterus 
are  various;  thus,  in  the  case  of  a  retro-deviation  the  fundus  drops 
backward  into  the  cul-de-sac,  in  a  position  of  either  version  or  flexion. 
In  either  of  them,  in  the  presence  of  more  or  less  acute  inflammation 
of  the  pelvic  peritoneum,  adhesion  is  likely  to  occur.  The  altered 
position  of  the  uterus  with  the  consequent  interference  with  the  circu- 
lation, particularly  on  the  venous  side,  results  in  a  mechanical  engorge- 
ment of  the  organ.  The  turgescence  results  in  enlargement,  increased 
weight  with  more  or  less  oedema,  and,  in  some  cases  of  long  standing, 
hyperplasia.  Corresponding  hematogenous  changes  are  also  mani- 
fested in  the  endometrium,  which,  at  the  menstrual  epoch,  is  liable  to 
become  hemorrhagic,  with  a  constant  tendency  to  more  or  less  metror- 
rhagia. When  the  displacement  is  associated  with  flexion  interesting 
changes  take  place  at  the  point  at  which  the  organ  is  bent.     On  its 


DISPLACEMENTS   OF   THE    UTERUS  287 

under,  or  concave,  surface,  there  occurs  an  amount  of  pressure,  varying 
according  to  the  degree  of  angulation,  upon  the  bent  and  approximated 
surfaces,  that  sooner  or  later  induces  atrophy  of  the  posterior  uterine 
wall  at  that  point.  While  these  changes  are  occurring  on  the  concave 
side  of  the  uterus,  opposite  changes  are  noticeable  on  the  upper  or  con- 
vex side,  where  the  tissues,  instead  of  being  subjected  to  abnormal  pres- 
sure, are  in  a  state  of  unnatural  tension.  The  anterior,  or  upper,  wall, 
yielding  to  this  tension,  presently  manifests  appearances  of  compensa- 
tory hyperplastic  development;  the  result  is  a  thinned,  relatively  atten- 
uated, uterine  wall  on  the  one  (concave)  side,  as  opposed  to  the  elon- 
gated and  redundant  wall  on  the  other  (convex)  side.  These  are  the 
cases  that  are  persistent  even  in  the  absence  of  adhesions.  In  other 
cases,  however,  particularly  those  in  which  the  displacement  has  fol- 
lowed upon  a  puerperal  metritis,  there  seems  to  have  occurred  more  or 
less  fatty  degeneration,  with  consequent  loss  of  tone  of  the  uterine 
parenchyma  and  resulting  abnormal  flexibility  of  the  uterus,  particu- 
larly at  the  cervico-corporeal  juncture.  In  these  cases  the  uterus  may 
be  found  in  a  state  of  anteflexion  one  day,  while  the  next  day  the 
surgeon  will  find  the  fundus  in  the  cul-de-sac.  Coincidently  with 
these  changes,  others  equally  marked  occur  in  the  uterine  ligaments. 
In  many  cases  associated  with  intrapelvic  infections  it  may  be  accepted 
as  true,  that  the  loss  of  tone  due  to  inflammatory  disturbances  in  the 
ligaments  themselves  constitutes  the  initial  change  in  the  development 
of  uterine  displacements;  but,  whether  causal  or  sequent,  relaxation 
with  elongation  of  the  ligaments  sooner  or  later  occurs.  The  utero- 
sacral  ligaments,  normally  taut,  become  distinctly  relaxed,  permitting 
the  cervix  to  go  forward,  while  the  round  ligaments  become  stretched 
and  permit  the  fundus  to  drop  backward;  or,  the  broad  ligaments,  the 
seat  of  an  infiltration,  cease  to  exercise  control  over  the  poise  of  the 
uterus.  While  these  changes,  essentially  inflammatory  in  character, 
permit  abnormal  mobility  of  the  uterus,  it  is  to  be  remembered  that 
sooner  or  later  occur,  in  structures  containing  considerable  connective- 
tissue  elements,  those  contractions  which  ensue  upon  the  absorption  of 
inflammatory  products.  The  essentially  atrophic  changes  in  this  stage 
of  the  inflammatory  process  result  in  contractions  more  or  less  marked 
in  all  the  involved  structures  except  the  round  ligaments,  and  pro- 
ductive of  more  or  less  distortion  of  the  uterus.  If  it  were  imaginable 
that  these  changes  would  occur  coincidently  and  equally  in  all  the  sus- 
pensory structures  of  the  uterus,  it  could  be  understood  that  that  organ 
would  thereby  be  drawn  back  to  its  normal  position  and  so  retained 
more  firmly  than  before.  Unfortunately  for  such  a  result,  however, 
the  round  ligaments  do  not  partake  of  the  contractile  changes,  while 
adhesions  generally  take  place  by  which  the  fundus  becomes  anchored 
in  the  cul-de-sac,  to  the  wall  of  the  bladder,  or  to  a  proximal  surface 
of  intestine;  or,  as  too  frequently  happens,  the  exudation  is  so  extensive 
as  to  involve,  not  only  the  uterus  and  the  approximated  peritoneal  sur- 
faces, but  also  tbo  Fallf)pian  tubes  and  the  ovaries,  in  the  general  agglu- 


288  A  TEXT-BOOK  OF   GYNECOLOGY 

tination.  Under  these  circumstances,  the  resulting  inflammatory  con- 
traction of  any  or  all  of  the  uterine  ligaments  can  not  do  otherwise 
than  develop  counter  traction,  causing  thereby  an  intensification  of  the 
general  intrapelvic  distress.  Occasionally,  the  inflammatory  process  with 
the  resulting  adhesion  occurs  on  but  one  side  of  the  pelvis,  or,  if  it  occurs 
on  both  sides,  one  side  undergoes  resolution  while  the  other  side  shows 
the  mischievous  results  of  exudation,  adhesion  and  lateral  displacement. 

The  ]Dathology  of  prolapsus  of  the  uterus  differs  materially  from 
that  in  which  there  exists  a  mere  deviation  from  the  normal  axis 
without  descent  of  the  organ  below  its  normal  plane.  It  is  indeed 
an  open  question  whether  prolapsus  of  the  uterus  should  be  patho- 
logically classified  merely  as  uterine  displacement;  for,  as  a  mat- 
ter of  fact,  the  descent  of  the  uterus  in  the  pelvis  is  but  little  more 
than  an  incident  in  a  series  of  broader  and  more  comprehensive  morbid 
changes.  It  is  doubtful  whether  descensus  uteri  should  be  considered 
otherwise  than  as  a  feature  of  a  general  intrapelvic  hernia.  The  pa- 
thology of  this  condition  involves  very  generally  an  enteroptosis,  a 
weakening  of  the  siispensory  apparatus  of  the  uterus,  and  a  relaxation  of 
the  pelvic  diaphragm  proper,  with  either  a  laceration  or  relaxation  of 
the  pelvic  floor.  The  frequent  occurrence  of  descensus  uteri  in  women 
who  have  never  borne  children  or  who  have  never  sustained  sexual 
relations,  indicates  that  this  form  of  hernia  frequently  occurs  inde- 
pendently of  puerperal  conditions.  It  may  be  held  as  true,  however, 
that  in  the  majority  of  cases,  the  impairment  of  all  the  structures  in- 
A^olved  in  this  condition  is  due  to  the  accidents  of  childbirth.  The  exer- 
cise of  undue  force,  involuntary,  manipulative,  or  instrumental,  may 
have  done  serious  damage  to  the  suspensory  apparatus;  or  the  undue 
distention  of  the  cervix,  resulting  in  its  laceration  or  in  the  laceration 
of  the  circumuterine  or  perimetric  fascia,  or  in  damage  to  the  floor  of 
the  pelvis  (see  Injuries  of  the  Floor  of  the  Pelvis),  may  have  laid  the 
foundation  for  this  form  of  visceral  extrusion.  Injuries  to  the  floor  of 
the  pelvis  alone,  if  permitted  to  persist,  may  induce  within  the  pelvis 
changes  that  will  permit  the  descent  of  its  contents.  This  occurs,  not 
from  the  removal  of  any  fancied  support  to  the  uterus,  but  from  the 
widening  of  the  vaginal  outlet  permitting  the  vaginal  walls,  the  rectum, 
and  the  bladder,  to  descend  and  to  exercise  undue,  and  finally  overpow- 
ering, traction  upon  the  uterus  and  its  normal  attachments.  It  thus 
happens  that  injuries  to  the  pelvic  floor  may  be  the  primary  and  causal 
condition,  while  the  reverse  may  be  equally  true. 

The  Treatment  of  Uterine  Displacements. — The  idea  that  uterine 
displacements  in  themselves  cause  little  or  no  harm  is  held  now  by 
very  few  gynecologists.  The  multitude  of  methods  which  have  been 
devised  for  curing  these  displacements  is  proof  that  the  vast  majority 
of  surgeons  see  in  them  something  which  needs  correction.  Mann  takes 
it  for  granted  that  uterine  displacements  in  themselves  have  an  im- 
portant pathological  bearing;  that  a  woman  with  a  displaced  uterus 
can  never  be  perfectly  well,  and  that  the  malposition  should,  there- 


DISPLACEMENTS  OF   THE   UTERUS  289 

fore,  be  corrected.  This  may  be  done  in  various  ways.  Unquestion- 
ably a  certain  proportion  of  downward  and  retro-deviations  may 
be  relieved  by  mechanical  devices — pessaries  of  various  kinds.  But 
these,  at  best,  are  rarely  curative,  giving  relief  only  while  they  are 
worn.  To  make  a  permanent  cure,  some  surgical  procedure  is  necessary, 
by  which  the  natural  supports  of  the  uterus  may  be  returned  to  their 
normal  condition,  or  else  some  new  support  may  be  added,  whereby 
the  uterus  shall  be  prevented  from  getting  out  of  place.  If  there  is 
any  exception  to  what  has  been  said,  it  is  in  regard  to  forward  dis- 
placements. The  tendency  to  their  surgical  treatment  has  diminished 
with  time,  and  now  very  few  operate  for  anteversion  or  anteflexion, 
except  by  dilatation  and  curetting.  Still,  there  are  cases  where  some 
other  surgical  operations  seem  to  be  demanded,  and  these  will  be  con- 
sidered. Prolapse  has  been,  and  still  is,  a  battle-ground  as  to  the 
proper  method  of  gaining  permanent  relief. 

It  is  the  firm  belief  of  Mann  that  more  good  can  be  done,  with 
less  risk,  in  the  surgical  treatment  of  uterine  displacements  than  in 
any  other  branch  of  gynecological  surgery.  The  mortality  of  these 
operations  in  themselves  should  be  nil.  Of  course  accidents  may  ha^^pen 
and  an  occasional  death  occur;  but  usually  they  may  be  considered 
as  being  in  themselves  without  danger  to  life.  The  dangers,  if  any, 
must  arise  from  the  serious  complications  which  are  often  coexistent 
with  the  displacement. 

Eetro-deviations  of  the  uterus  are  of  frequent  occurrence.  The 
combined  observations  of  Winckel,  Lohlein,  and  Sanger,  embracing 
several  thousand  patients,  show  that  retro-deviations  occur  in  17.74 
per  cent  of  all  gynecologic  patients.  These  displacements  may  cause 
no  appreciable  symptoms;  or,  on  the  other  hand,  they  may  create  such 
disturbance  that  they  may  properly  be  classified  among  the  most  dis- 
tressing and  persistent  maladies  with  which  a  woman  can  be  aiSicted. 
They  give  rise  not  only  to  local  discomfort  but  to  constitutional  ill 
health;  they  render  a  woman  unfit  for  the  marital  relation  and  are  the 
cause  of  sterility;  and  their  prompt  detection  and  effective  treatment 
are  among  the  most  imperative  duties  devolving  upon  the  practitioner. 

Symptoms  and  Diagnosis. — When  retro-deviation  occurs  suddenly, 
as  from  a  fall  or  a  Jump,  the  patient  complains  of  pain  low  down  in 
the  back,  sacralgia,  and  general  pelvic  discomfort.  This  discomfort 
may  at  times  become  a  sharp  lancinating  pain.  When  the  displace- 
ment is  of  longer  standing,  the  patient  complains  of  pain  in  the  back 
and  in  the  neighbourhood  of  the  sacrum  and  the  coccyx,  often  radiating 
down  the  legs,  frequently  into  the  external  pudendal  organs  and  often 
centring  in  the  clitoris.  This  pain  is  exaggerated  by  walking,  stair- 
climbing,  or  any  laborious  occupation.  Dysuria  is  generally  present, 
and  the  patient  sooner  or  later  complains  of  constipation.  This  latter 
condition  is  frequently  associated  with  other  disturbances  of  the  diges- 
tive tract,  causing  impairment  of  the  general  nutrition,  loss  of  flesh, 
and  the  general  appearances  of  anaemia.  The  diagnosis,  however,  will 
'20 


290 


A  TEXT-BOOK  OF   GYNECOLOGY 


Fig.  116. — "The  e.xamiuation  should  be  made  Trith 
the  patient  on  her  back  and  her  head  a  little  ele- 
vated."— Eeed. 


depend  upon  tlie  physical  conditions  discovered  by  local  examination. 
The  examination  should  be  made  with  the  patient  on  her  back  and  her 
head  a  little  elevated  (Fig.  116).  Digital  examination,  particularly  in 
the  case  of  retroversion,  will  reveal  a  change  in  the  uterine  axis,  mani- 
fested by  anterior  dis- 
placement of  the  cervix. 
If  the  finger  is  now  passed 
up  toward  the  cul-de-sac, 
a  mass  will  be  felt.  This 
may  be  due  to  a  loaded  sig- 
moid, a  subperitoneal  my- 
oma, an  enlarged  and  dis- 
placed ovary,  or  a  de- 
scended and  distended 
Fallopian  tube;  or  it  may 
be  the  fundus  of  the 
uterus.  At  this  point,  the 
diagnosis  will  be  material- 
ly facilitated  by  placing 
the  other  hand  over  the 
abdominal  wall,  when,  if 
the  condition  is  a  retro-deviation,  the  fundus  of  the  uterus  will  not 
be  discovered  in  its  normal  situation.  If  the  case  is  one  of  retro- 
flexion instead  of  retroversion,  the  point  of  angulation  can  generally 
be  discovered  by  the  tip  of  the  intravaginal  finger.  In  recent  cases  of 
uncomplicated  retro-deviation,  pelvic  engorgement  associated  with 
pronounced  tenderness  may  be  present,  and  may  temporarily  mask  the 
condition  of  the  uterus.  Eetro-deviations  frequently  exist  as  com- 
plications of  myomata,  and  of  inflammations,  enlargements,  and  dis- 
placements, of  the  appendages.  The  sound  was  formerly  employed 
as  a  means  of  diagnosis  in  these  cases,  but  so  much  damage  has  fol- 
lowed its  use  that  its  emiDloyment  in  this  connection  has  been  aban- 
doned by  judicious  practitioners.  An  index  finger  may  be  introduced 
into  the  rectum  whereby  some  additional  information  may  be  obtained. 
The  diagnosis  should,  however,  be  made  by  means  of  the  bimanual 
examination  and  Avithout  recourse  to  instrumental  or  other  exploration. 
The  treatment  of  retro-deviations  consists  in  the  application  of 
topical,  mechanical,  and  surgical,  measures.  The  first  step  in  the 
judicious  application  of  any  of  these  means  of  cure  must  consist  in 
determining,  with,  at  least,  approximate  accuracy,  not  only  the  exist- 
ence of  the  displacement,  but  of  the  various  complications  with  which 
it  may  be  associated.  Thus,  in  the  presence  of  a  metritis,  of  acute 
inflammation  of  the  Fallopian  tubes,  or  of  recent  intense  and  painful 
general  engorgement  of  the  pelvis,  all  manipulations  having  for  their 
object  the  reduction  of  the  displacement  should  be  interdicted.  In 
the  presence  of  these  conditions,  the  patient  should  be  put  in  the 
recumbent  posture  and  should  be  treated  with  salines,  hot  douches. 


DISPLACEMENTS  OF   THE   UTERUS 


291 


and  glycerine  tamponade,  until  the  acute  symptoms  have  subsided. 
When  there  are  no  contraindications  reposition  of  the  displaced  organ 
should  be  undertaken.  The  patient  should  be  placed  in  Sims's  position 
(see  Gynecological  Examinations),  or  she  may  be  placed  in  the  knee- 
elbow  posture  (Fig.  117).  With  the  index  finger  passed  toward  the 
cul-de-sac  and  pressing  against  the  fundus,  that  portion  of  the  uterus 
in  the  absence  of  adhesions  may  be  readily  thrown  forward.  The 
manipulation  is  sometimes  assisted  by  pressure  directed  toward  the 
cervix,  the  hand  being  placed  above  the  pubes  for  this  purpose.  The 
index  finger  passed  into  the  rectum  will  enable  the  operator  to  manipu- 
late the  fundus  of  the  uterus  with  more  force  and  precision.  The 
various  so-called  uterine  re- 
positors  are  to  be  looked 
upon  as  expedients  of  more 
than  doubtful  safety.  The 
old  practice  of  introducing 
a  curved  uterine  sound  and 
of  then  turning  it  round  in 
the  uterine  cavity  thus  forc- 
ing the  uterus  back  into  po- 
sition, has  been  denounced 
by  intelligent  gynecologists 
and  abandoned  by  consci- 
entious practitioners.  The 
practical  impossibility  of 
introducing  a  uterine  sound 

without  making  it  the  bearer  of  pathogenic  germs,  and  the  extreme 
probability  of  establishing  an  infection  atrium  by  its  use,  indicate  a 
danger  the  reality  of  which  has  been  confirmed  by  more  deaths  than 
have  been  honestly  recorded. 

Massage  has  been  employed  in  the  treatment  of  these  cases.  This 
consists  in  a  series  of  intrapelvic  manipulations  effected  by  means  of 
bimanual  operation,  whereby  the  uterus  is  subjected  to  pressure  and 
the  contracted  ligaments  and  adhesions  undergo  tension.  (See  Mas- 
sage.) It  goes  without  saying  that  this  method  of  treatment  is  contra- 
indicated  in  the  presence  of  infectious  conditions  of  the  uterine  adnexa 
and  of  the  pelvic  lymphatics.  The  extreme  difficulty  of  detecting  these 
conditions  renders  massage  a  dangerous  remedy,  a  fact  which  is  con- 
firmed by  its  general  abandonment  by  the  profession.  Electrolysis,  as 
employed  in  these  cases,  consists  in  the  application  of  strong  currents 
of  electricity,  for  the  purpose  of  causing  the  absorption  of  plastic  de- 
posits and  of  the  utero-peritoneal  adhesions  associated  with  retro-de- 
viations. Its  method  of  application  implies  the  repeated  introduc- 
tion of  an  electrode  into  the  uterus,  a  fact  which,  of  itself,  renders  it 
undesirable  as  a  systematic  treatment.  Tamponade  is  an  expedient  of 
great  value  in  the  treatment  of  these  cases.  If  the  tampon  is  carefully 
applied  and  is  of  the  proper  material,  it  will  furnish  to  the  displaced 


Fig.  117. — "  She  may  be  placed  in  the  knee-elbow 
posture." — Keed. 


292 


A  TEXT-BOOK   OP   GYNECOLOGY 


Fig.  118.—"  A  tampon  which  amounts  to  nothing  more  or 
less  than  a  large  plug  on  the  vagina." — Keed. 


uterus  an  important  mechanical  support,  while,  if  saturated  with 
glycerine,  the  exosmotic  property  of  the  latter  will  exercise  a  valuable 
influence    in    effecting    the    absorption    of    inflammatory    exudates. 

A  tampon,  however,, 
which  amounts  to 
nothing  more  or  less 
than  a  large  plug  in 
the  vagina  (Fig.  118), 
and  which  is  large 
enough  to  distend  the 
vulvar  orifice  when  it 
is  removed  and  re- 
quires considerable 
traction  to  remove  it, 
is  always  a  source  of 
damage.  The  repeated 
downward  traction 
thus  exercised  upon 
the  vaginal  wall  has  a 
tendency  to  drag  the  uterus  do^^^lward  in  the  pelvis  and  thus  to  aggra- 
vate the  very  condition  that  it  is  designed  to  remedy.  A  tampon 
properly  adjusted  should  occupy  the  upper  portion  of  the  vagina, 
should  not  exercise 
enough  pressure  to  oc- 
casion discomfort,  and 
should  be  so  con- 
structed that  its  re- 
moval will  not  involve 
traction  upon  the  pel- 
vic viscera.  The  well- 
known  chain  tampon 
(Fig.  119)  is  very 
good;  but  a  better  one 
consists  of  a  long  nar- 
row roll  of  either 
lamb's  wool  or  cotton, 
with  the  fibre  running 
lengtliAvise,  and  with 
a  string  attached  at 
one  end  (Fig.  120). 
The  ends  of  the  string 
are  left  about  6  inches 
long.  A  strand  of 
silkworm  gut  used  for 

this  purpose  is  very  desirable  because  of  its  lack  of  porosity.  The 
tampon,  10  or  13  inches  long,  or  even  longer,  is  now  passed  into 
the  vagina  through  a  speculum,  care  being  taken  that  it  does  not 


Fig.  119.—"  The  well-known  chain  tampon  is  very  good." 
— Eeed. 


DISPLACEMENTS   OP   THE   UTERUS 


293 


■extend  far  enough  down  in  the  canal  to  occasion  tenesmus.     'W'Tien 
;such  a  tampon  is  removed,  but  little  effort  is  required,  and  the  patient 
makes  no  complaint  of  the  dragging  and  pulling  that  is  the  unpleasant 
feature  in  the  removal  of  one  that 
is  improperly  constructed.     (See 
Nonsurgical    Treatment    of    Sal- 
pingitis.) 

Pessaries  have  long  been  em- 
ployed as  a  means  of  retaining 
the  replaced  uterus  in  position. 
In  the  decades  preceding  the  ad- 
vent of  the  present  successful 
surgery  of  the  pelvis,  pessaries 
were  very  generally  employed  in 
the  treatment  of  retro-deviations 
and  cures  were  reported  from 
their  use.  So  much  manifest  in- 
jury, however,  came  from  their 
employment  that  it  has  been  very 
largely  abandoned.  Of  the  vari- 
ous pessaries  employed  in  the 
treatment  of  this  condition,  one 
•devised  by  Albert  Smith  for  in- 
travaginal  application,  and  one  by 
■Gaillard  Thomas  for  extravaginal 
support,  were  probably  the  most 
successful.  If  pessaries  are  em- 
ployed the  following  axioms 
should  be  observed:  An  intra- 
uterine stem  should  never  be 
Tised;  no  pessary  should  be  ad- 
justed in  the  presence  of  either 
local  or  general  inflammation 
within  the  pelvis  ;  no  pessary 
should  be  adjusted  to  an  unre- 
duced displacement;  and  no  pes- 
sary should  be  continued  in  posi- 
tion after  it  begins  to  cause  pain, 
it  TY'ill  ^3e  discovered  that  there 


Fig.  120. — "  A  better  tampon  consists  of  a 
long  narrow  roll  of  either  lamb's  wool 
or  cotton,  with  the  tibre  running  length- 
wise, and  with  a  string  attached  at  one 
end."— Eeed  (page  292.) 


If  these  rules  are  carefully  observed 
are  but  very  few  pessaries  that  are 
adapted  to  the  treatment  of  these  cases. 

J.  Whitridge  Williams  (Maryland  Medical  Journal),  while  contend- 
ing for  the  value  of  pessaries,  says  that  it  can  not  be  asserted  that  they 
will  "cure  the  trouble  in  all  cases,  even  when  we  are  able  to  replace  the 
utf-rus.  ludcefl,  the  contrary  must  be  confessed,  if  by  cure  we  mean 
that  the  pessary  will  enable  the  uterus  and  its  supporting  structures 
to  reassume  their  normal  tone,  and  at  last  remain  in  place  without  its 
assistance.     Such  a  result  may  be  designated  as  an  absolute  cure,  and 


294  A  TEXT-BOOK   OF   GYNECOLOGY 

only  occurs  in  about  25  per  cent  of  the  cases  treated.  On  the  other 
hand,  in  a  much  hirger  proportion  of  cases,  the  uterus  remains  in 
place  and  all  the  symptoms  are  removed  as  long  as  the  pessary  is 
employed,  hut  recur  as  soon  as  it  is  removed.  These  we  may  designate 
as  relative  cures,  and  they  occur  in  from  40  per  cent  (Sanger)  to  60 
per  cent  (Klotz)  of  all  cases  conscientiously  treated." 

The  Surgical  Treatment  of  Retro-deviations. — Many  methods  have 
been  devised  for  the  curing  of  backward  displacements  of  the  uterus. 
These  may  be  included  under  three  headings:  First,  Shortening  the 
Eound  Ligaments;  secondly.  Ventral  Fixation  or  Suspension;  and, 
thirdly,  Vaginal  Fixation,  as  introduced  by  the  German  operators. 

Shortening  the  Round  Ligaments. — The  idea  of  shortening  the 
round  ligaments  for  the  cure  of  backward  displacements  of  the  uterus 
was  first  suggested  by  Alquie,  of  France,  in  1840.  This  suggestion  was 
not  favourably  received,  and  it  was  not  until  Alexander,  of  Liverpool, 
successfully  performed  the  operation  and  carefully  described  the  pro- 
cedure, that  the  operation  was  accepted.  Adams  performed  the  opera- 
tion independently  a  few  months  later;  but  it  was  undoubtedly  Alex- 
ander's monograph,  published  in  1884,  which  induced  other  operators 
to  follow  his  example,  and  placed  the  operation  on  a  firm  basis. 

The  idea  of  shortening  the  round  ligaments  internally  originated 
with  W.  Gr.  Wylie,  of  New  York,  who  operated  first  in  1886.  Bode,  in 
1888,  did  a  very  similar  operation.  Euggi  and  Frank,  also,  did  analo- 
gous operations  about  the  same  time.  The  operation  has  been  further 
modified  by  Polk,  Palmer  Dudley,  M.  Baudouin,  Mann,  and  others. 

The  shortening  of  the  round  ligaments  through  a  vaginal  incision 
was  first  done  by  Wertheim,  and  his  procedure  has  been  modified  and 
improved  upon  by  Bode  and  Kiefer,  in  Berlin,  and  by  Byford,  Vine- 
berg,  and  Goffe,  in  this  country. 

The  original  operation  of  Alexander  has  stood  the  test  of  time  and 
experience,  and,  with  slight  modifications  of  technique,  is  done  by  all 
who  operate  from  the  outside.  Within  the  abdomen,  the  operation  of 
Mann  is  accepted  by  many  as  the  best;  and  through  the  vagina,  the 
few  who  have  operated  in  this  country  have  generally  followed  either 
Byford  or  Gofi^e.  As  it  is  not  necessary  to  describe  the  various  steps  in 
the  evolution  of  these  operations,  only  the  three  named  will  be  fully 
described. 

Alexander's  Operation — Indications. — Alexander's  operation  may 
be  proijerly  j^jerformed  in  any  backward  or  downward  displacement  in 
which  there  are  no  adhesions.  Should  adhesions  exist,  if  not  too 
numerous,  they  may  be  broken  up  before  the  operation,  either  by  the 
conjoined  manipulation,  or,  better  still,  by  an  incision  through  the 
posterior  wall  of  the  vagina  into  Douglas's  pouch.  When  adhesions 
are  present,  there  is  usually,  also,  associated  disease  of  the  tubes  and 
ovaries;  so  that  in  the  majority  of  the  cases  of  this  kind,  in  Mann's 
opinion,  abdominal  section  with  intra-abdominal  shortening  of  the  liga- 
ments is  the  better  operation. 


DISPLACEMENTS   OF   THE   UTERUS  295 

Where  the  uterus  is  greatly  enlarged  and  the  utero-sacral  ligaments 
are  also  relaxed,  very  little  benefit  can  be  expected  to  follow  Alex- 
ander's operation  alone,  because,  although  the  fundus  may  be  held  for- 
ward, the  cervix  will  slide  down  under  the  symphysis  and  the  uterus 
will  again  get  into  the  axis  of  the  vagina,  so  that,  in  time,  the  round 
ligaments  will  give  way,  and  the  displacement  will  recur.  In  these 
cases  it  may  be  necessary  for  the  patient  to  wear  a  pessary  for  some 
time  after  Alexander's  operation,  or  the  utero-sacral  ligaments  may 
be  shortened,  or  Pryor's  plan  of  opening  into  Douglas's  pouch  and 
packing  this  with  iodoform  gauze  may  be  followed.     (>See  page  305.) 

Antiseptic  Precautions. — It  has  been  the  experience  of  many  opera- 
tors that  suiDpuration  is  quite  prone  to  occur  in  this  operation.  This 
can  be  readily  accounted  for  by  the  low  vitality  of  the  parts  involved — 
adipose  tissue  and  tendon — by  the  great  amount  of  handling  of  the 
tissues,  and  by  the  depths  of  the  cutaneous  folds  affording  safe  hiding 
places  to  the  Staphylococcus  pyogenes  albus  and  other  micro-organisms. 
Suppuration  can  generally  be  prevented  by  a  very  rigid  ase|)sis.  Un- 
questionably, the  fingers  of  the  surgeon  are  the  great  carriers  of  infec- 
tion. While  experiments  show  that  it  is  impossible  to  perfectly  steril- 
ize the  fingers^  still,  the  dangers  can  be  reduced  to  a  minimum  by  care- 
ful scrubbing  with  soap  and  hot  water,  and  subsequent  immersion  for 
at  least  five  minutes  in  a  l-to-1,000  sublimate  solution,  or  in  the 
potassium  permanganate  and  oxalic  acid  solutions. 

The  use  of  riiljljer  gloves  is  the  most  certain  way  of  preventing  in- 
fection from  the  hands,  and  they  should  never  be  omitted.  In  a  long 
series  of  cases  done  with  gloves,  not  a  single  supjjurative  case  has  been 
met  with.  While  the  gloves  at  first  seem  to  be  a  great  obstacle,  after 
a  little  practice  their  presence  is  scarcely  noticed. 

The  most  thorough  disinfection  of  the  jDatient's  skin  should  be 
employed.  After  careful  shaving,  the  parts  should  be  covered  with  a 
green-soap  poultice  for  some  hours,  and  then  thoroughly  scrubbed,  and 
a  cloth  wet  in  sublimate  solution  (1  to  1,000)  placed  over  them  and 
left  there  until  the  operation  begins.  Immediately  before  the  opera- 
tion, an  additional  scrubbing  with  alcohol  and  ether,  followed  by 
more  sublimate  solution,  will  diminish  the  chances  of  suppuration. 
During  the  operation  all  loose  i^ieces  of  fat,  torn  muscle,  or  fascia, 
should  be  removed,  and  all  blood  vessels  carefully  tied  or  twisted,  so 
as  to  prevent  the  formation  of  clots  as  far  as  possible.  It  must  not  be 
forgotten  that  the  cut  end  of  the  ligament  sometimes  bleeds  and  may 
need  a  fine  ligature. 

The  present  technique  of  the  operation  shows  that  no  improve- 
ments of  importance  have  been  made  in  the  original  plan  suggested  by 
Alexander.  The  patient,  being  properly  prepared,  is  placed  upon  the 
table  with  the  feet  toward  the  light.  The  uterus  must  first  be  carefully 
replaced  and  a  pessary  introduced.  In  most  instances  it  will  be  advis- 
able to  precede  this  by  a  thorough  curettage  of  the  uterus.  Should 
there  b*;  a  thorough  retroflexion,  it  may  sometimes  be  necessary  to 


296  A  TEXT-BOOK  OF   GYNECOLOGY 

introduce  a  stem  pessary,  in  order  to  make  the  uterus  rigid  and  to  pre- 
vent the  fundus  from  turning  over  round  the  pessary. 

Having  thoroughly  cleansed  the  skin  at  the  seat  of  operation  and 
surrounded  the  parts  with  antiseptic  towels,  wet  or  dry  as  the  opera- 
tor may  choose,  either  the  spine  of  the  pubis  or  the  external  abdominal 
ring  is  felt  for.  One  or  both  can  usually  be  readily  distinguished. 
An  incision  is  then  made  directly  over  the  ring,  a  short  distance  above 
Poupart's  ligament  and  parallel  to  it.  The  length  of  the  incision  will 
vary  with  the  amount  of  adipose  tissue  present.  In  many  thin  persons, 
the  incision  may  be  less  than  an  inch  in  length;  two  inches  is  the 
maximum  length  in  any  case.  The  fat  and  superficial  fascia  should  be 
carefully  incised  until  the  tendon  of  the  external  oblique  muscle  is 
clearly  and  distinctly  visible.  This  may  be  recognised  by  its  white  and 
glistening  appearance.  Between  the  fibres  of  this  tendon  may  be  seen 
the  covering  of  the  inguinal  canal,  which  is  recognised  as  a  somewhat 
darker  line  slightly  triangular  in  shape.  The  finger  tip  readily  recog- 
nises the  external  ring. 

With  the  scissors  the  intercolumnar  fascia  at  the  external  ring 
is  snipped,  and  immediately  a  small  mass  of  fat  will  extrude  itself. 
This  may  be  picked  up  between  the  thumb  and  finger  and  slowly  and 
carefully  raised;  or,  should  the  operator  prefer,  a  strabismus  hook  may 
be  introduced  and  the  tissues  within  the  canal  brought  forward.  These 
tissues  always  contain  the  cord  spread  out  in  fan-shape.  By  raising 
them  carefully,  the  whitish  fibres  of  the  cord  may  be  recognised.  It 
should  then  be  se^^arated  from  the  surrounding  connective  tissue  and 
also  from  the  nerve.  The  nerve  should  not  be  cut,  but  carefully  laid 
aside.  Then,  with  the  fingers  alone,  without  the  use  of  any  instrument, 
the  cord  should  be  slowly  and  carefully  pulled  out.  In  the  majority 
of  instances  it  comes  out  readily,  increasing  in  size  as  the  lower  por- 
tions are  brought  up,  until  a  large,  white,  fibrinous,  structure  is 
brought  well  in  view.  In  some  instances  the  pubic  portion  of  the  cord 
is  exceedingly  small  and  requires  the  most  careful  handling;  but,  if 
great  care  and  delicacy  are  used,  it  may  be  slowly  and  gradually 
brought  out  until  the  large  and  well-developed  cord  is  finally  secured. 
If  the  cord  comes  with  great  difficulty,  the  intercolumnar  fascia  may 
be  incised  and  tbe  whole  length  of  the  canal  laid  open,  thus  exposing 
the  cord  at  a  point  where  it  is  usually  larger  and  stronger. 

Having  been  once  brought  out,  the  cord  is  allowed  to  fall  back  into 
its  place,  the  pubic  end  being  still  connected,  and  the  same  procedure 
is  followed  upon  the  opposite  side.  Most  operators  prefer  to  change 
sides,  and  to  stand  upon  the  side  on  which  they  are  operating. 

The  length  to  which  the  cord  should  be  pulled  out  varies.  In 
simple  retroversions,  a  moderate  amount  of  shortening  is  all  that  is 
needed.  Should  the  parts  be  very  much  relaxed  and  the  uterus  en- 
larged and  prolapsed,  a  greater  amount  of  shortening  will  be  required. 
No  positive  rule  can  be  given  for  this;  the  judgment  of  the  operator 
must  decide  in  each  case.     Both  cords  beinff  loosened  and  all  hemor- 


DISPLACEMENTS  OP   THE   UTERUS  297 

rhage  stopped,  the  pubic  end  of  one  cord  is  cut  close  to  the  pubis,  and 
the  cord  drawn  out  and  held  by  an  assistant,  well  up  to  the  abdominal 
wall.  A  stitch  of  catgut  is  passed  through  one  pillar  of  the  ring,  and 
then  through  the  cord  and  the  opposite  pillar.  The  same  stitch  is  then 
passed  through  these  tissues  in  reverse  order,  the  two  ends  being 
brought  out  on  the  same  side.  This  mattress  suture  serves  to  keep 
the  cord  in  place  and  effectually  to  close  the  canal.  The  cord  is  then 
cut  off  half  an  inch  beyond  the  last  stitch.  Should  the  inguinal  canal 
be  still  open  to  any  extent,  this  should  be  closed  by  additional  catgut 
.stitches. 

This  procedure  having  been  completed  on  both  sides,  the  wounds 
are  closed  by  deep  stitches  of  fine  catgut.  An  antiseptic  dressing  is 
applied  and  held  in  place  by  adhesive  straps.  The  bandage  devised  by 
Dr.  Kelly,  and  known  by  his  name,  has  proved  very  serviceable  in  still 
further  holding  the  dressings  in  place. 

There  are  several  complications  to  be  taken  into  account  Adhesions 
in  the  inguinal  canal  sometimes  effectually  prevent  the  drawing  out 
of  the  cord.  In  three  cases  seen  by  Mann,  the  cord  was  so  firmly 
attached  on  one  side,  that  it  was  impossible  to  draw  it  out,  there 
having  been  in  each  case  an  inflammatory  condition  with  pus-formation 
in  the  neighbourhood  of  the  canal.  Upon  the  opposite  side,  in  each 
of  these  cases,  the  cord  was  drawn  out  as  usual.  It  is  questionable 
whether  the  operation  should  ever  be  undertaken  under  such  circum- 
stances. The  shortening  of  one  cord  is  hardly  sufficient  to  keep  the 
uterus  in  place,  although  it  may  help,  and  occasionally  succeeds  per- 
fectly. 

We  can  never  predict  whether  we  shall  encounter  a  delicate  cord  or 
a  strong  one,  in  any  given  case.  In  young  women  who  have  never 
borne  children,  or  in  whom  the  uterus  is  not  well  developed,  the  liga- 
ments are  sometimes  very  small  and  ill  defined.  In  women  who  have 
passed  the  menopause,  and  in  whom  the  uterus  is  atrophied,  the  atrophic 
process  seems  often  to  include  the  round  ligaments;  and  in  these  cases 
the  result  of  Alexander's  operation  is  not  so  sure.  From  these  or 
other  causes,  the  cord  is  at  times  so  delicate,  especially  at  the  pubic 
end,  as  to  be  pulled  out  with  the  greatest  difficulty.  Unless  the  utmost 
gentleness  is  used,  it  will  be  broken,  and  then  all  clew  to  its  position 
is  lost.  By  working  very  slowly  and  carefully,  and  opening  up  the 
inguinal  canal  to  its  full  extent,  the  cord  can  usually  be  pulled  out, 
even  in  the  worst  cases.  Considerable  time  must  be  taken,  as  hurry 
will  surely  result  in  failure. 

In  a  few  instances  the  cord  will  hrealc.  If  this  occurs  at  the  pubic 
end,  and  the  uterine  end  of  the  cord  can  be  kept  in  view,  it  may  be 
carefully  followed  up  until  it  becomes  large  enough  to  be  firmly  seized 
anrl  so  be  pulled  out.  It  is  impossible  to  pull  upon  the  cord  with  a 
homostat  or  any  instrument,  for,  no  matter  how  carefully  it  is  done,  it 
will  crush  and  cut  tbo  cord.  The  cord  must  always  be  pulled  with  the 
fingers,  iiiKJ   ilic  fiii.iivi's  alone.     As  the  gloved  fingers  are  slippery,  it 


298  A   TEXT-BOOK  OF   GYNECOLOGY 

is  well,  until  the  cord  is  entirely  loosened,  to  keep  its  pubic  end  attached. 
In  pulling  on  the  cord,  it  must  always  be  remembered  that  the  force 
should  be  applied  in  the  direction  of  the  inguinal  canal. 

If  the  uterine  end  of  the  cord  breaks  after  it  has  been  nearly  freed, 
the  difficulties  of  securing  it  again  are  very  great.  The  only  chance 
then  will  be  to  follow  up  the  inguinal  canal  and  to  open  into  the 
abdominal  cavity  through  the  internal  ring.  Goldspohn,  of  Chicago, 
recommends  that  the  internal  ring  should  be  opened  in  all  cases,  and 
he  inspects  and  operates  upon  the  tubes  and  ovaries  in  this  way.  Mann 
has  performed  this  operation  several  times,  removing  diseased  ovaries 
and  tubes  before  shortening  the  round  ligaments.  It  does  not  seem 
to  be  generally  advisable  to  adopt  this  procedure,  as  the  median  opera- 
tion, with  the  internal  shortening  of  the  round  ligaments,  would  seem 
to  be  safer  and  easier.  By  pulling  up  the  horn  of  the  uterus,  the 
broken  end  of  the  round  ligament  may  sometimes  be  found;  but  the 
operation  may  fail  because  the  cord  is  broken  so  close  to  the  uterus 
that  there  is  not  sufficient  to  sew  even  to  the  internal  ring. 

The  operator  is  sometimes  embarrassed  by  anatomical  abnormi- 
ties. In  a  few  instances,  the  cord  has  been  found  not  to  run  through 
the  inguinal  canal.  Doubt  may  be  thrown  upon  some  of  these  cases, 
as  only  the  most  careful  dissection  post-mortem  would  be  sufficient  to 
prove  that  the  cord  is  not  there.  Failure  to  find  the  cord  will  be  less 
frequent  as  the  operator  becomes  more  experienced.  By  keeping  the 
anatomic  landmarks  carefully  in  view,  and  by  making  sure  that  the  ten- 
dons of  the  external  oblique  muscle,  with  the  external  ring,  are  clearly 
exposed,  and  that  the  incision  is  made  between  the  pillars  of  the  ring 
and  not  to  one  side,  very  few  failures  will  be  encountered.  In  about 
1  per  cent  of  cases  the  canal  of  Nuck  will  be  found  to  be  open  from 
the  internal  ring  to  the  symphysis.  In  these  cases  the  round  ligament  is 
always  found  embedded  in  the  walls  of  the  canal  and  can  not  be  sepa- 
rated, and  the  shortening  of  the  ligaments  is  impossible.  The  fact  that 
there  is  a  persistent  canal  of  ISTuck  on  one  side  does  not  prove  that  the 
same  condition  exists  upon  the  opposite  side.  Inguinal  hernia  in  the 
female  is  comparatively  rare,  but,  when  found,  often  coexists  with  re- 
troversion. In  these  cases,  the  shortening  of  the  round  ligaments  and 
the  cure  of  the  hernia  can  be  done  together.  The  round  ligament  will 
usually  be  found  upon  the  hernial  sac,  and  must  be  carefully  searched 
for  before  the  sac  is  cut  off. 

The  after-treatment  is  very  simple.  The  patient  should  be  kept  in 
bed  for  eight  or  ten  days,  and  the  wound  left  untouched,  unless  the 
temperature  goes  up.  At  the  end  of  that  time  the  dressings  may  be 
removed;  when  the  wound  should  be  found  perfectly  healed.  Upon 
the  tenth  day,  the  patient  may  be  allowed  to  sit  up,  and  may  leave  her 
room  as  soon  after  as  her  strength  will  permit.  The  pessary  which 
was  introduced  at  the  time  of  the  operation  should  be  worn  for  two 
or  three  months;  and,  if  there  is  much  relaxation  of  the  utero-sacral 
ligaments,  it  may  be  necessary  to  keep  it  in  for  a  longer  period. 


DISPLACEMENTS   OP  THE    UTERUS  290 

Intra-abdominal  Shortening  of  the  Round  Ligaments— Mann's 
Operation. — The  operation  here  to  be  described  is  a  modilication  of 
the  procedure  first  suggested  by  Wylie  (Fig.  121).  It  has  been  de- 
scribed by  Mann  in  tlie  American  Gynecological  Transactions  for  1897. 
It  was  first  done  in  June,  1893. 

The  special  indications  for  this  operation  are  a  backward  displace- 
ment and  such  complications  with  other  diseased  conditions  as  to  make 
the  opening  of  the  abdomen  advisable.     It  can  be  done,  therefore, 


Fig.  121.—"  The  procedure  iirst  described  by  WyJie." — Mann. 

where  it  is  necessary  to  open  the  abdomen  for  reparative  work  on  dis- 
eased tubes  and  ovaries,  for  the  breaking-up  of  adhesions,  the  removal  of 
one  tube  and  ovary,  or  the  removal  of  ovarian  cyst  or  pedunculated 
fibroid.  It  may  also  be  done  when  Alexander's  operation  has  been  tried 
and  has  failed,  or  is  contraindicated  for  any  reason.  In  any  abdominal 
section  for  pelvic  disease,  if  the  uterus  is  displaced  backward,  this  or 
some  operation  having  a  similar  purpose  should  be  done.  Where  both 
tubes  and  ovaries  are  removed,  or  when  pregnancy  can  not  possibly 
occur,  some  might  prefer  ventral  fixation.  This  operation  does  not  com- 
pete with  Alexander's  operation,  as  it  fulfils  entirely  different  indications. 

The  abdomen  being  opened,  the  technique  of  the  operation  is  as 
follows:  Adhesions  are  broken  up,  and  any  other  necessary  operative 
procedure  completed.  The  patient  is  then  placed  in  the  Trendelen- 
burg position,  and  the  abdominal  retractors  put  in  place.  A  large, 
flat  sponge  is  spread  over  the  intestines,  and  the  uterus  is  seized  by  a 
small  volsella  forceps  and  pulled  up  to  the  abdominal  wound.  The 
round  ligament  on  one  side  is  made  tense  by  pulling  the  uterus  to  the 
opposite  side,  and  is  then  seized  by  two  hemostatic  forceps,  the  points 
of  seizure  dividing  the  ligament  as  nearly  as  possible  into  three  equal 
portions. 

Next,  a  needle,  threaded  with  silk,  is  passed  through  the  angle  in 
the  round  ligament  made  by  pulling  upon  the  hemostat.  This  passes, 
therefore,  twice  through  the  ligament  at  points  quite  near  to  each 
other.  It  is  then  passed  through  the  wall  of  the  uterus  at  the  point 
where  the  round  ligament  is  inserted  into  the  anterior  uterine  wall. 
It  is  well  that  a  considerable  quantity  of  uterine  tissue  be  included  in 
this  suture.  The  usual  method  of  passing  the  sutures  through  the 
anterior  wall  of  the  uterus  is  wrong  (Fig.  122). 


300 


A  TEXT-BOOK  OF  GYNECOLOGY 


The  hemostat  being  removed,  the  loop  of  the  ligament  is  tied  to  the 
uterus.  A  second  stitch  is  passed  through  the  ligament  just  as  it 
leaves  the  abdominal  wall,  and  then  through  the  second  angle  in  the 
round  ligament  at  the  site  of  the  other  forceps.     This  ligature  is  tied 


Fig.  122. — "  The  usual  method  of  passing  the  suture  through  the  anterior  wall  of  the 
uterus  is  wrong." — Mann  (page  299). 

and  cut  as  before.  In  this  waj  the  ligament  is  doubled  on  itself,  and 
three  thicknesses  of  round  ligament  are  stretched  between  the  sides 
of  the  pelvis  and  tlie  wall  of  the  uterus.  The  same  thing  being  done 
upon  the  opposite  side,  the  wound  is  closed  in  the  usual  manner. 

Eeed  has  adojDted  Mann's  operation 
as  the  one  of  choice  in  practically  all 
retro-deviations  of  the  uterus.  He  em- 
plo3's  a  forceps,  having  four  flat  approxi- 
mating prongs,  the  whole  being  an  inch 
or  more  wide,  with  which  to  seize  the 
round  ligament  in  its  middle  (Fig.  123). 
A  half  turn  of  the  forceps  makes  the  de- 
sired fold  in  the  round  ligament  (Fig. 
12-i).  The  folds  of  the  ligament  are  now 
fixed  at  the  uterine  and  parietal  ends  as 
already  described,  interrupted  sutures 
being  emploj^ed;  the  middle  zone  is  next 
fixed  by  a  continuous  suture  passed  be- 
tween the  prongs  of  the  forceps.  The 
result  is  a  triplicate  ligament  of  desirable 
shortness  and  great  strength  (Fig.  125). 
The  character  of  the  suture  material 
with  which  the  round  ligaments  are 
sewed  up  is  of  some  importance.  Silk- 
worm gut  is  satisfactory,  and  has  been 
used  in  many  cases  without  harm;  and, 
should  an  abscess  occur  and  the  removal  of  the  suture  be  found  neces- 
sary, it  can  be  more  easily  found  than  a  suture  of  any  other  material, 
as  the  sharp  cut  ends  can  be  appreciated  by  the  sense  of  touch.  Catgut, 
which  is  readily  absorbed,  may  produce  adhesions,  but  the  adhesions  are 


Fig.  123. — "  A  forceps  with  four  flat 
approximating  prongs,  the  whole 
being  an  inch  or  more  wide." 
— Eeed. 


DISPLACEMENTS  OF   THE   UTERUS 


301 


not  always  permanent,  and  some  cases  of  failure,  or,  rather,  of  recur- 
rence, have  been  reported.  In  one  case  operated  on  by  Mann,  in  which 
catgut  was  used,  in  the  year  subsequent  to  the  original  operation  all 
traces  of  the  doubling  of 
the  ligaments  had  disap- 
peared. For  this  reason 
an  unabsorbable  ligature 
seems  preferable. 

The  results  as  shown 
by  a  number  of  cases 
which  have  been  reported 
by  different  operators 
have  been  satisfactory. 
When  pregnancy  has  oc- 
curred after  this  opera- 
tion, the  labour  has  been 
entirely  normal  in  each 
instance.  As  the  uterus 
is  held  in  its  normal  posi- 
tion, and  as  the  round 
ligaments  can  stretch  and 
grow  as  well  as  they  could 
were  they  not  stitched  to- 
gether, there  is  no  reason 
why  pregnancy  and  la- 
bour should  be  interfered 
with  in  any  way  by  this 
operation. 

The  after-treatment  is 
that  which  is  usual  for 
cases  of  abdominal  sec- 
tion. 

For  those  who  prefer 
the  vaginal  route,  the  op- 
erations of  Goffe  or  Byford  for  shortening  of  the  round  ligaments 
through  the  vagina  are  practical  and  give  good  results,  though  they  are 
confessedly  more  difficult  of  performance  than  where  the  round  liga- 
ments are  shortened  through  an  abdominal  incision. 

For  those  who  are  skilled  in  vaginal  work,  this  operation  may  be 
indicated  whenever  the  uterus  is  displaced,  whether  there  are  adhesions 
and  tubal  and  ovarian  disease  or  not.  Unless  the  adhesions  are  very 
dense  and  the  disease  of  the  adnexa  extensive,  they  can  all  be  treated 
through  the  vagina,  thus  widening  materially  the  indications  for  this 
operation  over  that  of  Alexander,  and  bringing  it  in  direct  competition 
with  the  abdominal  operation. 

Gaffe's  Ojierfilhiii. — (JofFc,  after  placing  the  patient  in  the  dorsal 
posifion,  uIHi  the  lliiglis  well  flexed,  seizes  the  cervix  through  a  specu- 


FiG.  124.—''  A  half  turn  of  the  forceps  now  makes  the 
desired  fold  in  the  round  ligament."— Eeed  (page  300). 


302 


A  TEXT-BOOK  OF  GYNECOLOGY 


lum,  and  pulls  it  strongly  away  from  the  pubis.  An  incision  is  then 
made  halfway  round  the  uterus,  through  the  vaginal  wall.  Another 
incision  at  right  angles  to  this,  in  the  median  line,  converts  the  opening 
into  a  T-shaped  incision.  Through  this,  the  bladder  is  carefully  sepa- 
rated from  the  vaginal  wall  by  the  finger,  and  the  peritoneum  opened. 

The  fundus  of  the  uterus 
is  next  pulled  down  until 
the  round  ligaments  are 
brought  into  view.  They 
are  then  doubled  upon 
themselves  in  two  places, 
much  as  in  Mann's  opera- 
tion. It  is  impossible, 
however,  to  get  the  out- 
side stitch  as  near  the 
l^elvic  wall  as  is  done 
when  the  abdomen  is 
opened.  Otherwise,  the 
operation  is  practically 
the  same.  With  the 
uterus  pulled  down 
through  the  vaginal 
wound,  the  tubes  and 
ovaries  can  be  inspected 
and  operated  on,  if  de- 
sired, and  adhesions 
Ijroken.  After  the  liga- 
ments have  been  short- 
ened, the  vaginal  wound 
is  closed  with  catgut  su- 
tures and  a  small  open- 
ing for  drainage  left, 
if  thought  desirable, 
though  usually  this  is 
unnecessary.  The  vagina 
is  then  dusted  with  iodo- 
form, and  the  patient 
placed  in  bed. 
Byford's  operation  differs  from  the  procedure  of  Goffe  in  that  he 
draws  down  the  fundus  of  the  bladder  and  stitches  the  fundus  of  the 
uterus  to  the  post-pubic  peritoneum,  which  is  drawn  down  after  the 
bladder  but  recedes  upward  when  released,  and  draws  the  fundus 
with  it.  The  fundus  is  thus  sutured  to  the  peritoneum  over  the  blad- 
der, much  in  the  same  way  as  in  abdominal  hysteropexy. 

For  the  suture  of  the  bladder  to  the  fundus,  he  uses  formalinized 
catgut,  placing  two  stitches  about  an  inch  apart.  He  draws  down  the 
round  ligaments  and  uterine  horns  into  the  vagina,  suturing  the  for- 


FiG.  125. — "The  result  is  a  triplicate  ligament  of  desir 
able  shortness  and  great  strength." — Eeed  (page  300). 


DISPLACEMENTS   OF   THE   UTERUS  303 

mer  as  taut  as  possible  to  the  uterus  just  above  the  uterine  insertion. 
As  he  finishes  the  suturing  of  the  ligament,  he  throws  the  same  catgut 
thread  around  the  neck  of  the  loop  thus  formed,  and  ties  it  securely. 
This  last  step  he  considers  an  important  detail.  He  pays  no  attention 
to  the  remainder  of  the  loop,  which  forms  adhesions  to  the  bladder 
and  uterus  just  below  the  sutures.  After  all  intraperitoneal  oozing  has 
ceased,  he  closes  the  peritoneum  with  fine  catgut  and  the  vaginal  wound 
in  the  ordinary  way. 

Byford  asserts  that  the  simple  shortening  of  the  round  ligament  is 
not  sufficient,  because,  if  it  depends  simply  on  adhesions,  these  ad- 
hesions will  stretch  and  give  way,  and  allow  a  recurrence  of  the  dis- 
placement. This  objection  does  not  hold  if  a  nonabsorbable  ligature 
is  used  in  the  shortening  of  the  ligaments.  Byford  reports  a  number 
of  cases  with  generally  satisfactory  results. 

The  principal  complication  which  is  likely  to  give  trouble  is  narrow- 
ness of  the  vagina.  This  is  particularly  the  case  in  virgins  and  in 
women  past  the  change  of  life,  in  whom  atrophy  has  occurred.  The 
narrow  vagina  makes  the  operation  very  much  more  difficult,  and  may 
be  a  positive  contraindication  unless  the  operator  is  an  adept.  Exten- 
sive disease  of  the  tubes  or  ovaries  may  also  contraindicate  this  method 
of  operating,  and  may  even,  where  it  has  been  begun,  necessitate  its 
abandonment,  and  the  opening  of  the  abdomen  instead. 

This  method  has  the  great  advantages  of  rapid  recovery,  absence  of 
an  unsightly  scar,  and  freedom  from  danger  of  ventral  hernia.  As 
compared  with  the  abdominal  operation,  it  is  more  difficult  of  perform- 
ance, requires  a  large  experience  in  vaginal  work,  and  occasionally  it 
is  even  necessary  to  open  the  abdomen  to  complete  it — this,  however, 
only  in  the  presence  of  formidable  complications.  As  compared  with 
Alexander's  operation,  it  is  much  more  difficult  and  more  dangerous. 
In  simple  cases  the  vaginal  operation  should  always  give  way  by  prefer- 
ence to  the  Alexander. 

Vag-inal  Fixation. — Under  this  heading  Mann  includes  all  those 
operations  which  have  for  their  purpose  the  fixation  of  the  uterus 
through  the  vagina.  Either  the  body  or  the  neck  of  the  uterus  can  be 
fixed  directly;  or  it  can  be  fixed  indirectly  by  acting  upon  the  vaginal 
walls. 

Fixation  of  the  fundus  originated  with  Eabenau  (1886);  but  at  pres- 
ent there  are  a  number  of  methods  of  performing  it  in  use,  and  no  one 
fixed  method  seems  to  be  generally  adopted.  The  operation  employed 
hy  Miiller  is  as  follows:  After  curetting  in  the  usual  way,  the  uterus  is 
pushed  into  a  position  of  anteflexion  by  means  of  Orthmann's  instru- 
ment, and  drawn  strongly  downward.  (See  Macnaughton  Jones, 
Diseases  of  Women.)  The  anterior  vaginal  wall  is  then  cut  from  the 
point  of  insertion  into  the  cervix  almost  to  the  meatus  urethrge.  If  a 
cystocele  is  present,  an  oval  of  mucous  membrane  upon  the  anterior 
vaginal  wall  is  removed.  The  bladder  is  then  separated  from  the 
vagina,  ilie  forinor  Ijcing  drawn  up  and  held  by  a  retractor.     Great  care 


304  A  TEXT-BOOK  OF  GYNECOLOGY 

must  be  taken  to  have  the  bladder  thoroughly  separated,  in  order  to 
avoid  injur}^  by  suture  or  pressure  by  the  uterus.  The  fundus  is  then 
reached;,  and  half  a  dozen  strong  catgut  sutures  are  next  passed  trans- 
versely in  the  anterior  uterine  wall,  beginning  at  the  wound  above. 
The  points  of  entrance  and  exit  of  the  stitches  are  2  centimetres  apart. 
Then  these  stitches  are  carried  through  the  edges  of  the  wound,  1  centi- 
metre from  the  margins.  The  sutures  are  not  tied  yet,  but  the  vaginal 
wound  is  closed;  after  which  Orthmann's  instrument  is  removed  and 
the  sutures  tied  in  the  order  of  insertion.  The  uterus,  being  in  a  posi- 
tion of  anteversion,  is  held  there  by  a  firm  tamponade  of  the  vagina 
with  iodoform  gauze.  In  MacJcenrodfs  operation,  after  separation  of 
the  bladder  from  the  uterus  and  the  opening  of  the  abdominal  cavity,, 
the  anterior  flap  of  the  peritoneum  is  stitched  to  the  front  of  the 
uterus,  and  then  to  the  posterior  surface  of  the  bladder,  thus  closing 
the  vesico-uterine  pouch.  A.  Martin  does  an  intraperitoneal  vaginal 
fixation  after  colporrhaphy  in  a  somewhat  similar  way.  In  this  coun- 
try, Yineberg  has  practised  an  operation  which  involves  both  the  short- 
ening of  the  round  ligaments  and  the  anterior  fixation  of  the  uterus. 
All  of  these  operations  of  anterior  fixation  have  the  very  great  dis- 
advantage that  they  interfere  more  or  less  with  pregnancy;  and  in  the 
earlier  cases,  where  the  fundus  was  fixed  to  the  vagina,  very  serious 
results  followed.  These  earlier  methods  have  been  almost  entirely 
given  up,  and  seem  to  have  very  little  place  in  gynecological  practice. 

Besides  the  methods  described,  there  are  a  variety  of  others,  each 
operator  seeming  to  have  a  plan  of  his  own.  It  is  not  thought  advisable 
to  multiply  descriptions  of  slight  modifications  of  technique. 

Fixation  of  the  cervix  has  been  attempted,  the  object  being  to  fasten 
it  back  in  the  hollow  of  the  sacrum.  It  can  be  readily  understood  that, 
if  the  cervix  is  held  upward  and  backward  in  the  sacrum,  the  fundus 
will  be  thrown  forward.  This  may  be  done  either  by  shortening  the 
utero-sacral  ligaments,  or  by  causing  adhesions  between  the  posterior 
surface  of  the  cervix  and  the  rectum — in  other  words,  by  obliterating 
Douglas's  cul-de-sac.  The  operation  for  shortening  the  utero-sacral 
ligaments  has  not  been  successful,  no  technique  having  been  developed 
which  could  make  the  operation  available.  Mann  made  attempts  to  do 
this  a  number  of  years  ago,  putting  the  patient  in  the  Trendelenburg 
position.  In  this  way  each  utero-sacral  ligament  was  folded  upon 
itself  and  sewed  with  catgut.  In  some  cases  it  may  be  done  with  com- 
parative ease,  but  in  the  majority  of  cases  it  is  a  very  difficult  matter,, 
and  the  results  have  not  been  altogether  satisfactory.  Freund  has 
proposed  to  shorten  these  ligaments  by  sewing  them  to  the  posterior 
wall  of  Douglas's  pouch.  Probably  the  best  operation  is  that  sug- 
gested by  W.  E.  Pryor.     His  plan  is  as  follows : 

Pryor's  operation  is  done  by  preparing  the  patient  locally  and  gen- 
erally as  for  a  capital  operation.  After  the  uterus  is  curetted,  the  cul- 
de-sac  is  opened,  the  patient  being  in  the  dorsal  position.  If  no  pus 
is  found,  the  operation  is  then  continued.     The  tubes  and  ovaries. 


DISPLACEMENTS   OP   THE   UTERUS  305 

are  treated  as  circumstances  may  require.  After  this,  the  pelvis  is 
wiped  dry  and  a  gauze  pad  inserted.  The  patient  is  placed  in  the 
Trendelenburg  position  and  the  gauze  pad  removed.  After  the  uterus 
has  been  packed  with  iodoform  gauze,  a  piece  of  the  gauze  suffi- 
ciently wide  to  fill  the  vaginal  opening,  and  about  an  inch  and  a  half 
long,  is  inserted  just  within  the  edges  of  the  vaginal  wound.  Over  this 
enough  strips  are  placed  to  fill  the  incision  in  the  vagina.  The  uterus 
is  then  put  in  place,  the  gauze  plug  being  carefully  retained  in  position. 
Holding  the  uterus  in  place  by  the  tampons  pu^shing  against  the  cervix, 
pieces  of  gauze  are  inserted  to  the  sides  of  the  cervix  and  in  front  of 
it,  until  the  vagina  is  filled  to  the  margin  of  the  levator-ani  muscle. 
The  operator  now  takes  a  stout  roll  of  gauze,  as  thick  as  his  thumb, 
and  about  two  inches  long.  This  Pryor  calls  the  gauze  pessary.  One 
end  of  this  is  introduced  in  front  of  one  side  of  the  cervix,  just  behind 
the  levator-ani  fibres,  and  the  other  end  is  pushed  into  a  similar  posi- 
tion on  the  other  side.  This  plug  lies  transversely  across  the  vagina 
and  in  front  of  the  cervix.  It  will  prevent  the  descent  of  the  cervix, 
even  in  the  face  of  the  most  severe  vomiting.  The  uterine  packing 
should  be  so  arranged  that  it  can  be  removed  without  disturbing  the 
anchoring  plug.     (Fig.  36,  p.  120,  Pelvic  Inftammations,  Pryor.) 

A  self -retaining  catheter  is  introduced  and  is  left  in  for  two  days. 

The  after-treatment  is  important.  In  from  seven  to  ten  days,  the 
patient  is  placed  in  Sims's  position  and  all  the  dressings  are  removed 
and  replaced  exactly  as  they  were  at  first.  The  operation  will  fail 
unless  the  supporting  plug  is  properly  inserted.  Dressings  are  con- 
tinued as  long  as  there  is  any  raw  surface  in  the  vaginal  vault.  The 
supporting  tampon  is  used  for  six  weeks.  The  cervix  must  be  kept 
pressing  high  and  backward  until  the  cul-de-sac  opening  closes  and 
the  posterior  cervical  scar  is  healed. 

Among  the  advantages  claimed  for  this  operation  are  that  it  leaves 
the  corpus  uteri  perfectly  in  place,  pregnancy  is  uninterrupted,  and 
labour  normal.  The  laceration  and  diseases  of  the  cervix  and  peri- 
neum, according  to  Pryor,  are  to  be  corrected  by  subsequent  operations, 
and  not  done  at  the  time  of  the  cul-de-sac  operation.  This  is  certainly 
a  disadvantage  as  compared  with  Alexander's  operation,  which  may 
very  properly  be  joined  with  the  various  plastic  operations  on  the 
vagina,  cervix,  and  perineum. 

This  operation  may  he  done  in  any  case  of  retroversion,  and  is  espe- 
cially indicated  when  the  utero-sacral  ligaments  are  relaxed,  particu- 
larly in  cases  of  retroversion  with  prolapse.  It  may  be  combined  with 
Alexander's  operation  in  cases  of  great  relaxation.  When  the  back- 
ward position  is  accompanied  by  occluded  tubes,  by  hydrosalpinx,  or  by 
cystic  ovaries,  Pryor  thinks  this  is  the  preferable  operation;  but  when 
pus  is  present  in  either  tube  or  ovary,  he  thinks  laparotomy  preferable. 

Ventral  Fixation. — Under  this  head  it  is  proposed  to  consider  all 
tlie  operations  by  wliich  the  uterus  is  fastened,  either  directly  or  indi- 
rectly to  tlie  abdoininal  wall.  According  to  Delageniere,  this  opera- 
21 


306  A  TEXT-BOOK  OF   GYNECOLOGY 

tion  was  first  done  in  1869,  by  Koebeiie,  avIio,  after  removing  an  ovary, 
.fastened  the  pedicle  into  the  abdominal  wound.  Lawson  Tait  first 
fixed  the  body  of  the  uterus  to  the  abdominal  wall  by  passing  a  ligature 
through  the  fundus  and  through  the  edges  of  the  wou.nd.  These  two 
operations  represent  the  direct  and  indirect  methods  which  have  been 
developed  by  later  operators. 

Direct  fixation  of  the  fundus  to  the  abdominal  wall  may  be  accom- 
plished in  two  ways — either  by  passing  ligatures  so  as  to  simply  ap- 
proximate the  peritoneal  surfaces;  or  the  fundus  may  be  sewed  to 
other  structures  of  the  abdominal  walls.  In  the  first  method  the  suture 
is  passed  first  through  the  fascia,  subperitoneal  fat  and  peritoneum, 
and  then  through  the  posterior  wall  of  the  uterus  a  little  below  the 
fundus.  It  then  passes  through  the  opposite  edge  of  the  wound,  com- 
ing out  above  the  fascia.  A  similar  stitch  is  passed  a  quarter  of  an 
inch  nearer  the  umbilicus  and  a  little  lower  upon  the  uterine  wall. 
These  stitches,  when  tied,  approximate  the  posterior  surface  of  the 
fundus  to  the  abdomen;  adhesions  then  form,  and  in  time  the  perito- 
neum pulls  down,  forming  what  has  been  described  as  a  "  suspensory 
ligament." 

The  second  method  is  employed  in  cases  of  great  enlargement  of 
the  uterus,  and  particularly  in  cases  of  prolapse,  in  which  the  adhesions 
formed  by  the  first  method  are  not  sufficient  to  permanently  support 
the  uterus.  Under  these  circumstances,  it  is  well  to  attach  the  uterus 
more  firmly.  It  may  then  be  drawn  out  of  the  abdominal  wound  and 
the  peritoneum  sewed  with  a  running  suture  entirely  around  the  fun- 
dus, going  farther  down  upon  the  posterior  wall  than  upon  the  ante- 
rior. In  this  way  half  an  inch  of  the  fundus  is  brought  above  the 
peritoneum.  It  is  then  sewed  firmly  with  buried  catgut  stitches  to  the 
fascia  and  the  edges  of  the  recti  muscles.  In  this  way  very  firm 
adhesions  are  formed  and  the  most  obstinate  case  of  prolapse  may  be 
relieved.  Kelly  inserts  the  sutures  through  the  peritoneum  and  fascia 
in  such  fashion  that,  when  tied,  the  knots  are  within  the  peritoneal 
cavity  (Fig.  126).  In  Mann's  experience  this  method  is  satisfactory, 
but  should  never  be  performed  in  cases  where  pregnancy  may  possibly 
occur.  It  is  especially  indicated  in  women  past  the  menopause,  in 
whom  very  great  relaxation  of  the  vagina  and  perineum  exists. 

The  needle  which  should  be  used  in  this  operation  should  have  no 
cutting  edge.  The  needles  known  as  Emmet's  vesico-vaginal-fistula 
needles  are  particularly  appropriate,  having  large  eyes  and  a  round 
body  with  a  slight  curve.  If  such  needles  are  used  no  hemorrhage  will 
occur  from  the  puncture  of  the  uterine  tissue.  If  the  uterus  is 
brought  up  against  the  line  of  the  abdominal  incision,  sufiicient  adhe- 
sions will  take  place.  If,  however,  it  is  brought  up  against  a  portion 
of  peritoneum  which  has  not  been  cut,  then  either  the  uterus  or  the 
peritoneal  surface  against  which  it  is  brought  should  be  scarified. 
The  early  operators  used  silk,  but  to-day  nearly  all  writers  recommend 
the  use  of  catgut.     The  chromatized  or  formalinized  catgut  is  prefer- 


DISPLACEMENTS   OF   THE   UTERUS 


}or 


able,  as  it  lasts  longer  and  creates  more  irritation,  and  stronger  adhesions 
are  consequently  formed.  By  bringing  the  posterior  surface  of  the 
uterus  in  contact  with  the  abdominal  wall,  intra-abdominal  pressure  is 
brought  to  bear  upon  the  posterior  surface  in  such  a  way  that  there  is 
no  tendency  to  a  recurrence  of  the  malposition. 

The  indications  for  this  operation,  by  either  method,  would  seem 
to  be  limited  to  those  cases  in  wliich  pregnancy  is  impossible,  and  where 


Fig.  120  (liedrawn  from  Kelly). — "  Kelly  inserts  the  sutures  through  the  peritoneum  and 
fascia  in  such  fashion  that  when  tied  the  knots  are  within  the  peritoneal  cavity." — Mann 
(page  306). 

the  abdomen  is  opened  for  some  other  purpose;  also  to  cases  of  very 
severe  prolapse  with  great  relaxation,  as  already  mentioned.  Where 
there  is  a  possibility  of  pregnancy  the  operation  should  not  be  done, 
as  a  large  number  of  cases  have  been  reported  where  pregnancy  and 
labour  have  been  materially  interfered  with  by  the  binding  down  of 
the  fundus  uteri. 

Indirect   Ventral  Fixation. — Dr.   A.   H.   Ferguson   (Journal  of   the 
American  Medical  Association,  November  18,  1899)  describes  a  method 


308 


A  TEXT-BOOK  OF   GYNECOLOGY 


of  transplanting  the  round  ligaments  and  attaching  them  to  the  abdomi- 
nal wall.  After  the  usual  preliminary  antiseptic  precautions,  he  opens 
the  skin  of  the  abdomen  in  the  median  line,  the  incision  being  three 
inches  in  length  and  beginning  an  inch  and  a  half  above  the  sym- 

phj^sis.  The  linea  alba 
and  the  anterior  sheath 
of  the  recti  muscles  are 
exposed,  and  an  incision 
is  made  on  either  side 
through  the  anterior 
sheath  of  the  rectus. 
The  rectus  muscle  is 
retracted  outward,  and 
an  incision  is  made  di- 
rectly behind  it  into 
the  peritoneal  cavity 
through  the  transversalis 
fascia  and  the  perito- 
neum. 

Next,  the  round  liga- 
ment and  the  portion  of 
the  broad  ligament  are 
seized  by  forceps  one 
inch  from  the  origin  of 
the  former  at  the  inter- 
nal ring.  These  struc- 
tures are  then  tied,  ex- 
ternally to  the  forceps, 
and  divided  (Fig.  127). 
The  distal  end  of  the 
round  ligament  is 
dropped  into  the  peri- 
toneal cavity,  and  the 
I^roximal  end  is  also 
pulled  well  out  of  the 
wound  into  it.  The 
round  ligament  and  its  accompanying  portion  of  the  broad  ligament 
are  next  sewed  with  catgut  to  the  margins  of  the  wound  in  the  trans- 
versalis fascia  and  peritoneum  (Fig.  128).  The  fibres  of  the  rectus 
muscle  are  then  replaced,  and  the  opening  in  the  anterior  sheath 
closed  with  continuous  catgut  suture,  which  gras^DS  the  end  of  the 
round  ligament. 

A  similar  operation  is  carried  out  upon  the  other  side  of  the  median 
line,  and  the  incision  closed. 

Dr.  Ferguson  claims  in  this  way  to  get  a  firm  support  for  the  uterus, 
which  is  not  adherent  to  the  abdominal  wall,  but  is  suspended  free  in 
the  pelvis  and  capable  of  motion.    He  reports  twenty-two  cases  operated 


l-'iii.  1-J7. — "Next  [in  Fergusson's  operationj,  the  round 
ligament  and  the  portion  of  the  broad  ligament, 
are  seized  by  forceps,  one  inch  from  the  origin  of  the 
former  .  .  .  tied  .  .  .  and  divided." — Mann. 


DISPLACEMENTS   OF   THE   UTERUS 


309 


on  in  two  and  a  half  years,  with  ideal  results.     One  of  the  patients  be- 
came pregnant,  and  the  pregnancy  went  on  to  normal  termination. 

The  indications  for  this  operation  are  the  same  as  for  intra-abdomi- 
nal shortening  of  the  round  ligaments,  for  which  it  may  be  substituted. 

In  comparing  these  various  operations  for  the  treatment  of  posterior 
displacements,  it  will  be  seen  that  each  has  its  special  indications,  and 
no  operator  should  become  so  attached  to  one  method  as  to  employ 
this  to  the  neglect  of  the  others.  Alexander's  operation  unquestion- 
ably fulfils  the  indications  in  a  large  majority  of  simple  cases.  Where 
adhesions  have  occurred, 
if  they  are  slight,  they 
may  be  broken  up 
through  a  vaginal  inci- 
sion, and  Alexander's 
operation  done  after- 
ward. 

In  view  of  the  excel- 
lent results  obtained  by 
Alexander's  operation, 
the  opening  of  the  abdo- 
men for  ventral  fixation 
alone  is  scarcely  war- 
ranted in  simple  cases. 
Where  the  abdomen  is 
opened,  and  the  tubes 
and  ovaries  left  in  such  a 
condition  that  pregnancy 
may  occur,  then  the  in- 
tra-abdominal shortening 
of  the  round  ligaments 
would  seem  to  offer  bet- 
ter chances  of  perma- 
nent cure  without  inter- 
ference with  gestation. 

If  serious  disease  of 
the  tubes  and  ovaries  ex- 
ists, then  either  the  ab- 
domen must  be  opened  or 
the  vaginal  operation 
done,  as  the  operator  may 
elect.  For  an  operator 
with     small     experience, 

the  abdominal  operation  unquestionably  offers  the  fewer  obstacles.  For 
those  skilled  in  vaginal  work,  the  vaginal  operation  causes  the  woman 
the  least  trouble  and  annoyance  from  the  operation.  Where  the  abdo- 
men is  opened  for  other  cause,  and  pregnancy  is  rendered  impossible, 
either  by  disease,  age,  or  the  operation,  then  ventral  fixation  would  seem 


Fig.  128. — "  The  round  ligament  and  its  accompanying 
portion  of  the  broad  ligament  are  next  sewed  with 
catgut  to  the  margins  of  the  wound  in  the  transver- 
salis  fascia  and  peritoneum." — Mann. 


310  A   TEXT-BOOK   OF   GYNECOLOGY 

to  be  the  simplest  and  easiest  of  performance,  and  to  give  promise  of 
equally  good  results.  Vaginal  fixation  has  found  little  favour  in  this 
country,  and,  in  view  of  the  great  difficulties  encountered  where  preg- 
nancy has  followed,  should  never  be  done  in  women  liable  to  become 
pregnant.  The  tendency  in  this  country,  even  among  those  who  have 
been  its  advocates,  seems  to  be  to  substitute  some  other  form  of  opera- 
tion for  it. 

Anterior  Abdominal  .  Cuneohysterectomy  for  Retroflexion  of  the 
"Uterus. — In  1895  Eeed  applied  Thiriar's  operation  of  cuneohysterectomy 
to  the  anterior  wall  of  the  uterus  for  the  relief  of  retroflexion.  Jonnesco 
made  a  similar  adaptation  of  the  operation  in  1897.  The  technique 
does  not  differ  in  any  essential  particular  from  that  described  in  the 
treatment  of  anterior  displacements  of  the  uterus,  except  that  the  site 
of  operation  is  the  anterior  instead  of  the  posterior  wall.  Reed  has 
done  the  operation  but  a  very  few  times  because  the  indications  in 
retro-deviations  generally  are  more  effectively  met  by  the  operations 
upon  the  uterine  ligaments,  as  described  under  another  heading.  The 
operation  of  anterior  cuneohysterectomy  is  indicated  only  in  those  cases 
of  retroflexion  presenting  marked  hypertrophy  with  induration  of 
the  convex  wall.  When  this  condition  exists,  the  removal  of  an  ellip- 
tical segment  is  necessary  to  restore  the  organ  to  its  normal  axis. 

Jonnesco  and  Reed  perform  this  operation  in  connection  with 
shortening  of  the  round  ligaments. 

Ante-deviations. — The  facts  that  the  uterus  occupies  normally  a 
position  of  anteversion  and  that  there  are  no  definite  lines  by  which  its 
normal  position  may  be  prescribed  and  limited,  make  it  relatively  diffi- 
cult to  determine  when  an  anterior  displacement  exists  in  a  pathological 
degree.  This  is  particularly  true  of  anteversion;  while  the  detection 
of  a  point  of  flexure  in  the  axis  of  the  uterus  on  its  anterior  surface  is 
conclusive  evidence  of  the  existence  of  an  anteflexion. 

The  symptoms  of  forward  displacements  are  pain  in  the  sacral 
region  with  more  or  less  vesical  irritation  and  tenesmus;  dysmenorrhoea 
and  sterility  are  usually  present.  The  diagnosis  is  generally  made 
without  difficulty  by  bimanual  examination.  The  fundus  is  felt  to 
occupy  a  position  anterior  to  its  normal  plane,  the  cervix  generally 
pointing  backward.  If,  with  the  patient  lying  upon  her  back,  the 
finger  is  passed  behind  the  cervix  and  the  latter  is  drawn  forward  to- 
ward the  pubis,  the  fundus  will  naturally  be  drawn  upward  and  back- 
ward; and  if,  when  the  force  is  removed  from  the  cervix,  the  uterus 
returns  to  the  state  of  extreme  anteversion,  it  may  be  known,  not  only 
that  forward  displacement  exists  to  a  pathological  degree,  but  also 
that  the  anterior  wall  of  the  uterus  is  attached  to  the  fundus  of  the 
bladder.  The  existence  of  a  point  of  flexure  on  the  anterior  wall  about 
the  cervico-corporeal  junction  will  establish  the  difference  between 
anteversion  and  anteflexion.  It  should  be  remembered  that  a  small 
subperitoneal  fibroid  on  the  anterior  wall  may  feel  like  anteflexion — and 
the  difference  may  not  be  detected  without  the  use  of  the  sound  or  an 


DISPLACEMENTS   OF   THE   UTERUS  311 

abdominal  section.  The  sound  ought  to  be  employed  only  under 
circumstances  of  exceptional  importance. 

The  pathology  of  ante-deviations,  like  that  of  other  forms  of  dis- 
placement, is  not  confined  to  the  uterus  itself,  but  embraces  a  con- 
sideration of  imjDortant  changes  in  its  suspensory  apparatus.  In  the 
organ  itself,  however,  in  anteversion  there  frequently  exists  a  condition 
of  hyperplasia,  and,  occasionally,  of  neoplastic  growth  that  makes  the 
organ  toi3-heavy,  as  it  were,  and  acts  as  a  potent  cause  in  producing 
and  maintaining  a  displacement.  In  other  cases  of  anteversion  paren- 
chymatous changes  are  sequent  rather  than  causal.  When  this  devia- 
tion exists  to  such  a  degree  as  to  interfere  mechanically  with  the  circu- 
lation— particularly  on  the  venous  side — more  or  less  passive  conges- 
tion of  the  organ  results.  This  is  expressed,  not  only  in  the  gross 
enlargement  of  the  uterus,  but  in  the  thickening  and  excessive  epithe- 
liah  growth  of  the  endometrium.  In  anteflexion  important  structural 
changes  are  added  to  those  already  enumerated.  If  the  angle  of  flexure 
is  acute,  atrophy  of  the  uterine  wall  occurs  at  the  point  of  angulation 
on  the  concave  side,  while  hyjDertrojDhy  is  likely  to  occur  on  the  con- 
vex side  (Fig.  131).  (See  Pathology  of  Eetro-deviations.)  Contrac- 
tion of  the  utero-sacral  ligaments,  whether  as  a  cause  or  as  a  conse- 
quence, generally  exists  in  connection  with  forward  displacements.  It 
is  probably  a  causative  factor  in  many  cases  and  one  to  be  taken  in 
account  in  the  treatment.  When  the  uterus  is  displaced  forward  in 
an  extreme  degree,  the  fundus  of  the  uterus  riding  upon  the  fundus  of 
the  bladder,  adhesion  of  the  proximal  peritoneal  surfaces  is  liable  to 
occur,  particularly  in  the  presence  of  infectious  infiammator}^  condi- 
tions within  the  pelvis.  When  this  complication  exists,  there  is  always 
more  or  less  inflammatory  mischief  in  the  wall  of  the  bladder.  Ex- 
treme ante-deviations  imply  more  or  less  constant  tension  on  the  broad 
ligaments,  which,  sooner  or  later  yielding  to  this  influence,  become 
relaxed  and  cease  to  exercise  their  function  of  holding  the  uterus  in 
its  natural  poise. 

The  treatment  of  forward  displacements  of  the  uterus,  aside  from 
surgical  measures,  has  been  unsatisfactory.  Pessaries,  while  occasion- 
ally affording  temporary  relief,  have  more  frequently  caused  discomfort 
and  damage.  Graily  Hewitt's  cradle  pessary  at  one  time  had  a  con- 
siderable vogue,  but  it,  like  its  congeners,  is  now  generally  abandoned. 
The  judicious  use  of  tampons  has  been  attended  with  comfort  and  fol- 
lowed by  substantial  improvement.  When  acute  pain  exists  with  for- 
ward displacements  the  patient  should  go  to  bed,  take  a  laxative,  and 
be  given  frequently  repeated  hot  douches,  with  occasional  glycerine 
tampons.  A  case  that  can  be  controlled  by  a  pessary  can,  in  all  proba- 
bility, be  relieved  with  equal  efficiency  and  greater  comfort  by  the 
measures  Just  enumerated.  When,  however,  in  spite  of  careful  atten- 
tion to  the  details  given,  forward  displacements  exist  to  such  a  de- 
gree as  to  interfere  with  health,  recourse  should  be  had  to  surgical 
treatment. 


312 


A  TEXT-BOOK  OP   GYNECOLOGY 


Forward  displacements  of  the  pregnant  uterus  occur  either-  by  re- 
laxation of  the  abdominal  wall  or  by  a  ventral  hernia.  Sometimes  the 
entire  gravid  ntertis  occupies  a  large  hernial  sac  (Fig.  129).  A  sup- 
port should  be  furnished  to  the  protruding  mass  until  delivery  lessens 
its  volume  and  renders  it  reducible.     The  case  after  this  period  is  to  be 

recognised  and  treated  as 
one  of  ventral  hernia. 

The  surgical  treatment 
of  forward  displacements 
has  as  yet  embraced  no 
operation  for  anteversion 
of  the  uterus.  Where  that 
condition  is  due  to  retrac- 
tion and  shortening  of 
the  utero-sacral  ligaments 
pulling  the  cervix  upward 
and  backward,  and  thus 
throwing  the  fundus  too 
far  forward,  it  has  been 
proposed  to  cut  through 
the  posterior  vaginal  wall 
and  resect  the  ligaments, 
thus  allowing  the  cervix 
to  come  forward  and  as- 
sume a  more  normal  posi- 
tion. This  operation  is 
rarely  necessary. 

It  has  also  been  pro- 
posed to  do  Alexander's 
operation  in  these  cases, 
and  to  raise  the  fundus  by  the  round  ligaments.  As  the  round  liga- 
ments were  never  made  for  this  purpose,  it  is  not  likely  that  the  opera- 
tion would  be  permanently  successful.  At  any  rate,  these  operations 
have  never  achieved  a  position  in  gynecological  surgery,  and  are  rarely 
even  mentioned  in  literature. 

A  history  of  the  operations  Avhich  have  been  devised  for  the  cure 
of  pathologic  anteflexion  would  form  a  very  interesting  chapter.  From 
the  operations  of  Simpson,  Sims,  and  Peaslee,  down  to  the  present  time, 
very  many  operations  have  been  devised,  all  having  for  their  object  the 
straightening  of  the  uterine  canal.  The  earlier  operations  of  Sims  were 
not  successful,  owing,  however,  largely  to  the  conditions  in  which  they 
were  done — the  want  of  a  proper  aseptic  technique.  The  later  opera- 
tions which  have  been  done  have  been  much  more  successful  and  satis- 
factory. The  majority  of  operators,  however,  are  content  with  the 
operation  of  forcible  dilatation,  usually  conjoined  with  curetting. 

Dilatation  and  Curetting". — This  was  suggested  by  Dr.  Jolm  Ball, 
of  Brooklyn,  in  1877  {New  Yorh  Medical  Journal,  vol.  xviii,  p.  363). 


Fig.  129. — "  Sometimes  the  entire  gravid  uterus  occu- 
pies a  large  Jiernial  sac." — Eeed. 


DISPLACEMENTS  OP   THE   UTERUS  313 

Ellinger  did  a  similar  operation,  and  Goodell  modified  Ellinger's  dilator 
and  followed  Ball's  method,  and  was  the  first  to  popularize  it  in  this 
country.  Hanks  also  operated  about  the  same  time,  using  graduated 
dilators  instead  of  the  expanding  dilators  of  the  other  operators.  That 
dilatation  is  better  than  cutting  is  now  generally  admitted,  and  the 
large  number  of  good  results  which  have  followed  it  has  made  this 
one  of  the  most  beneficent  operations  in  gynecological  surgery.  That 
it  cures  the  fiexion  is  not  asserted  by  its  most  ardent  supporters;  but 
that  the  flexion  is  benefited  and  the  symptoms  relieved,  is,  in  the  major- 
ity of  cases,  generally  admitted. 

This  operation  is  indicated  in  any  uncomplicated  case  of  anteflexion 
where  the  flexion  seems  to  be  productive  of  symptoms.  There  is  usu- 
ally present  an  endometritis,  and  this  has  more  to  do  with  the  symp- 
toms than  the  flexion,  and  is,  in  turn,  largely  the  result  of  the  flexion. 
The  operation  has  in  view,  not  so  much  the  cure  of  the  flexion,  as  the 
relief  of  the  complication — that  is,  the  endometritis. 

TecJmique. — The  patient  being  anaesthetized  and  placed  upon  the 
table,  with  the  hips  overhanging  the  edge  and  the  thighs  held  in  place 
by  suitable  legholders  or  assistants,  the  vagina  is  thoroughly  scoured 
with  gauze  and  green  soap.  The  advisability  of  this  procedure  has 
been  doubted  by  some,  as  it  is  a  well-known  fact  that  the  normal  vagina 
is  aseptic.  While  this  is  generally  admitted,  it  is  not  true  in  morbid 
conditions;  and,  as  we  can  hardly  make  a  complete  bacteriological  in- 
vestigation in  every  case,  it  is  better  to  be  upon  the  safe  side  and 
thoroughly  to  wash  out  and  disinfect  the  vagina.  After  the  scrubbing 
with  the  green  soap,  the  vagina  should  be  washed  with  a  solution  of 
bichloride  (1  to  3,000).  An  Edebohls's  or  Jones's  speculum  is  then 
introduced,  and  the  cervix  seized  with  the  traction  forceps  and  pulled 
down  toward  the  vulva.  After  the  direction  of  the  cervical  canal  has 
been  carefully  made  out  by  the  uterine  sound,  a  small  uterine  dilator 
(Hanks's  or  Palmer's)  is  introduced,  and  suificient  dilatation  effected 
to  admit  the  introduction  of  the  Ellinger-Goodell  dilator.  With 
this  the  cervix  may  be  forced  open,  at  least  up  to  the  inch  and  a  quar- 
ter mark  upon  the  index.  A  few  minutes  should  be  allowed  for  this, 
as  the  uterus  is  sometimes  very  friable,  and  too  rapid  dilatation  may 
tear  the  tissues.  When  the  dilatation  is  complete,  the  uterus  should 
be  washed  out  with  the  bichloride  solution,  and  then  thoroughly 
curetted  with  the  Sims  sharp  steel  curette.  After  this,  it  is  again 
washed,  and  packed  with  iodoform  gauze. 

Some  operators,  instead  of  packing  with  gauze,  prefer  to  introduce 
a  large  stem  pessary,  half  an  inch  in  diameter,  and  then  to  pack  the 
upper  part  of  the  vagina  around  the  stem  with  iodoform  gauze. 

If  the  cavity  of  the  uterus  has  been  packed  with  gauze,  the  gauze 
may  be  removed  on  the  fourth  day,  or  sooner  if  it  causes  too  much 
pain.  Tf  the  glass  stem  has  been  introduced,  upon  the  fifth  day  the 
stern  shoiilrl  be  withdrawn,  the  interior  of  the  uterus  carefully  washed 
out  witli    pci-oxidc  of  hydrogen,  and  mopped  out  with   a  5-per-cent 


314  A  TEXT-BOOK  OF  GYNECOLOGY 

solution  of  iclithyol  and  glycerine.  Tlie  stem  should  then  be  reintro- 
duced, and  a  tampon  of  cotton  or  iodoform  gauze  put  in,  to  keep  it  in 
place.  This  procedure  should  be  carried  out  daily  until  all  the  tender- 
ness upon  the  interior  of  the  uterus  has  disappeared. 

The  patient  should  be  kept  in  bed  for  four  days,  though  she  may 
be  allowed  to  sit  upon  the  commode  for  the  purpose  of  emptying  the 
bladder  and  bowels.  After  this,  she  may  be  up  and  dressed,  and  gradu- 
ally resume  her  ordinary  mode  of  life. 

In  this  way  a  very  large  proportion  of  cases  will  be  relieved,  not 
always  of  the  anteflexion,  but  of  the  symptoms  to  which  the  anteflexion 
has  given  rise. 

Dudley's  Operation. — Dr.  E.  C.  Dudley,  of  Chicago  (Diseases  of 
Women,  1898),  recommends  an  operation  for  anteflexion  which  has  for 
its  object,  not  only  the  curing  of  the  endometritis,  but  also  the  com- 
plete correction  of  the  deformity.  Mann  has  had  some  experience 
with  this  operation,  and  has  been  entirely  satisfied  with  the  results, 
although  his  cases  have  not  been  numerous  enough  to  enable  him  to 
speak  with  a  great  deal  of  positiveness.  Dudley,  however,  recom- 
mends the  operation,  and  it  certainly  accomplishes  what  he  claims  for 
it — namely,  the  complete  rectification  of  the  displacement. 

Technique. — The  operation  is  done  as  follows:  The  patient  is  placed 
in  Sims's  position,  and  the  speculum  is  introduced  under  ether.  The 
uterus  is  then  dilated  and  curetted  in  the  usual  manner.  The  cervix 
is  divided  with  scissors,  backward  in  the  median  line,  past  the  utero- 
vaginal attachment,  nearly  to  the  utero-peritoneal  fold,  in  the  pouch 
of  Douglas  (Fig.  381,  Dudley). 

"  The  cut  surfaces  thus  incised  are  then  held  widely  apart  by  means 
of  two  tenacula  in  the  hands  of  an  assistant;  the  incision  is  somewhat 
deepened  by  means  of  a  scalpel,  especially  in  the  uterine  wall  next  to 
the  cervical  canal,  and  a  small  angle  is  cut  out  on  either  side,  as  shown 
by  the  dotted  lines  in  Fig.  383.  The  cut  surface  on.  each  side  is 
now  folded  on  itself  by  a  single  silkworm  gut  suture,  as  shown  in  Fig. 
382.  This  suture  is  tied  and  fortified  by  interrupted  sutures  on  either 
side.     The  lines  of  union  thus  made  are  shown  in  Fig.  383. 

"  These  sutures  are  not  introduced  in  such  a  manner  as  to  stitch 
the  intracervical  to  the  vaginal  margin  of  the  wound,  but  the  cut 
surface  is  folded  upon  itself  in  a  direction  at-  right  angles  to  this.  On 
either  side,  that  point  at  the  margin  of  the  os  externum  where  the  back- 
ward incision  commenced  is  stitched  to  the  very  angle  of  the  incision, 
so  that  each  cut  surface  is  folded  upon  itself,  not  from  within  outward, 
but  from  before  backward.  Thereby  the  os  externum  is  carried  di- 
rectly back  to  the  angle  of  the  incision.  The  cervix  now  points  back- 
ward in  its  normal  direction  toward  the  hollow  of  the  sacrum,  instead 
of  forward  toAvard  the  vaginal  outlet  (see  Fig.  383). 

"  In  some  cases  of  extreme  anteflexion,  there  is  a  disproportionately 
long  anterior  lip.  This  elongation  is  shown  by  the  dotted  line  in 
Fig.   377.     It  is  the  result   of  a  relatively  greater  pressure   on  the 


DISPLACEMENTS  OF   THE   UTERUS  315 

posterior  lip  by  the  posterior  vaginal  wall;  this  lip  should  be  caught 
with  the  tenaculum  and  partially  removed  by  the  scissors.  The  incised 
surface  is  then  closed  upon  itself  with  sutures  as  shown  in  Fig.  384. 
The  dotted  line  in  Fig.  377  shows  in  section  the  line  of  incision  through 
the  protruding  lip;  the  incision  should  extend  to,  but  not  into,  the 
OS  externum.  This  part  of  the  operation  is  not  required  unless  the 
anterior  lip  decidedly  protrudes,  and  is  therefore  usually  omitted.  The 
removal  of  a  portion  of  the  lip  in  a  suitable  case  is  not  only  not  a 
mutilation,  but  it  even  contributes  to  the  straightening  of  the 
uterus. 

"  Conjoined  examination  upon  completion  of  the  operation  in  each 
of  the  author's  cases  has  invariably  shown  the  uterus  either  to  have 
been  straightened  or  the  anteflexion  to  have  been  reduced  to  a  degree 
quite  within  physiological  limits.  The  results  have  been  substantially 
the  same  whether  the  point  of  flexure  was  at  the  os  internum  or  be- 
low it. 

"  The  two  posterior  lines  of  sutures  have  the  effect  of  transplanting 
the  OS  externum  to  the  very  angle  of  the  posterior  incision.  The  an- 
terior sutures,  if  used,  have  the  effect  of  carrying  the  cervix  back  by 
a  distance  equal  to  one  half  the  length  of  the  anterior  cut  surface, 
which  is  doubled  upon  itself.  By  these  means  a  permanent  change, 
quite  equal  to  overcoming  the  flexure,  is  effected  in  the  direction  of 
the  cervix.  As  the  result  of  the  anterior  portion  of  the  operation,  the 
uterus  in  a  suitable  case  is  lifted  also  in  a  higher  plane  in  the  pelvis, 
where  it  ceases  to  be  a  mechanical  irritant  to  the  bladder.  This  por- 
tion of  the  operation  may  therefore  be  indicated  for  descent  when 
complicated  with  anteflexion."  (Dudley,  Diseases  of  Women,  p. 
581,  etc.) 

This  operation  is  not  a  substitute  for  dilatation  and  curetting,  but 
rather  supplementary  thereto. 

An  operation  called  cuneolujsteredomy  has  been  devised  for  the 
cure  of  anteflexion.  It  is  done  by  abdominal  section  and  consists  in 
removing  a  cuneiform  piece  of  tissue  from  the  convex  side  of  the 
uterus  at  the  point  of  angle.  Its  object  is  to  straighten  the  anteflexed 
uterus  by  reducing  to  normal  dimensions  its  elongated  posterior  wall. 
When  done  on  the  posterior  Avail  it  is  called  posterior  cuneohysterec- 
tomy,  and  vice  versa.  The  procedure  was  devised  and  practised  by 
Thiriar  in  1893.  Eeed  did  it  for  the  first  time  in  1894.  The  details 
of  the  operation,  as  he  has  modified  and  now  practises  it,  are  as  fol- 
lows: The  patient  is  prepared  with  the  usual  aseptic  and  other  pre- 
cautions for  abdominal  section.  An  incision  about  12  centimetres 
in  length  is  made  in  the  median  line  and  is  carried  as  low  as  practicable 
with  safety  to  the  bladder.  The  patient  is  now  placed  in  the  Trende- 
lenburg position.  All  adhesions  between  the  uterus  and  bladder  or 
between  the  uterus  and  other  organs  are  carefully  broken  up,  and 
rents  in  the  serosa  that  may  be  induced  thereby  are  carefully  stitched. 
The  uterus  is  then  brought  toward  the  incision  by  gentle  but  firm 


316 


A  TEXT-BOOK  OF  GYNECOLOaY 


traction  and  an  ellipse  of  tissue  about  1  centimetre  wide,  and  hav- 
ing a  length  corresponding  to  the  breath  of  the  organ,  is  removed 

from  the  convex  side 
of  the  site  of  flexure 
(Fig.  130).  Care  must 
be  taken  not  to  carry 
this  dissection  into 
the  cavity  of  the 
uterus  (Fig.  131), 
or  to  wound  either 
the  circular  artery 
or  the  anastomosing 
branches  of  the  uter- 
ine arteries.  Should 
the  latter  accident 
occur,    its    result    is 


Fig.  130. — ".  .  .  an  ellipse  of  tissue  about  one  centimetre 
wide,  and  having  a  length  corresponding  to  the  breadth 
of  the  organ,  is  removed  from  the  convex  side  at  the  site 
of  flexure."— Reed. 


best  counteracted  by 
ligatures  en  masse  passed  deeply  into  the  uterine  tissue  at  either  end 
of  the  yet  gaping  ellipse.  Retraction  of  the  vessels  generally  prevents 
their  isolation  and  closure 
by  direct  ligature  which, 
when  practicable,  is  al- 
ways the  preferable  meth- 
od. After  all  hemorrhage, 
except  mere  capillary  ooz- 
ing, is  controlled,  the 
margins  of  the  ellipse 
should  be  carefully  ap- 
proximated and  closed  by 
an  interrupted  suture,  or 
a  continuous  animal  su- 
ture fortified  with  two  or 
three  interrupted  ones  of 
the  same  material.  The 
uterus  is  then  dropped 
back,  and,  after  pausing 
a  moment  to  make  sure  of 
complete  hemostasis,  the 
abdomen  is  closed  with- 
out drainage.  A  further 
modification  of  this  op- 
eration, and  one  which 
Eeed  has  practised  with 
satisfaction,  consists  in 
stitching    a    reef    of    the 

posterior      folds      of      the        p^,  131.— "Care  must  be  taken  not  to  carry  this  dis- 
broad    ligament    to    either  section  into  the  cavity  of  the  uterus."— Reed. 


DISPLACEMENTS   OP   THE    UTERUS 


317 


side  of  the  posterior  surface  of  the  uterus  (Fig.  132).  The  utero- 
sacral  ligaments,  if  found  contracted,  are  nicked  and  stretched.  He 
has  been  able  by  these  combined  methods  to  relieve  the  most  dis- 
tressing and  persistent  symptoms,  vesical,  uterine,  ovarian,  and  neuro- 
tic, due  to  otherwise 
intractable  anteflex- 
ion of  the  womb. 

Prolapsus  Uteri. 
• — Prolapsus  is  that 
anomaly  of  position 
of  the  uterus  in  which 
the  organ  has  shifted 
from  its  normal  site, 
has  descended  or  fall- 
en to  a  lower  level, 
and     projects     partly 

or  completely  outside  of  the  vulva  (Fig.  133).  According  to  the  degree 
of  the  descent  we  distinguish  between  partial  or  total  prolapse.  There  is 
only  a  difference  in  degree  between  these  varieties,  their  entire  etiology 


Fig.  132. — "  A  further  modification  .  .  .  consists  in  stitch- 
ing a  reef  of  the  posterior  folds  of  the  broad  ligament  to 
either  side  of  the  posterior  surface  of  the  uterus." — Eeed. 


?aHiiPHWS 


I'lo.   loo. — '■  Trolapsus  is  that  anomaly  of  poisition  in  which  tlie  uterus  projects  partly  or 
completely  outside  the  vulva." — Herzog. 


being  tJie  same,  and  they  do  not  call  for  a  separate  consideration.  Par- 
tial prolapse  is  frequently  spoken  of  as  descensus  uteri;  the  term  pro- 
lapsus is  then  reserved  for  the  total  prolapse. 


318  A   TEXT-BOOK   OF  GYNECOLOGY 

ProlaiDsus  uteri  is  almost  invariably  an  acquired  condition^  though 
there  have  been  reported  by  Ballantj-ne  and  Thomson,  Heil,  Krause, 
and  Eemy  and  Quisling,  a  few  eases  of  congenital  prolapse.  These 
cases  Avere  always  found  in  connection  with  other  congenital  anoma- 
lies. A  condition  simulating  partial  prolaj^se,  which,  however,  anatom- 
icall}^,  as  well  as  from  an  etiological  point  of  view,  is  entirely  different 
from  the  morbid  condition  under  discussion,  is  that  of  primary  hyper- 
ti'ophy  of  the  jjortio  vaginalis  uteri.  This  anomaly  is  always  congeni- 
tal, and  it  may  and  does  secondarily  lead  to  a  true  prolapse. 

There  exists  still  a  good  deal  of  controversy  as  to  the  etiology  and 
mechanism  of  prolapsus.  A  view  formerly  held  almost  universally, 
and  still  adliered  to  by  some,  is  that  the  primary  factor  in  the  produc- 
tion of  a  prolapse  of  the  uterus  is  the  prolapse  of  the  vagina.  The 
latter  again  is  traced  back  to  a  subinvolution  during  the  puerperium. 
This  opinion  is  contested  by  Ktistner,  who  has  studied  the  subject 
extensively  and  who  very  clearly  and  forcibly  elaborates  his  observa- 
tions and  views  in  a  most  excellent  treatise  (Veit's  Handbucli  der 
Gijndlvlogie,  Wiesbaden,  189T,  vol.  i,  p.  168).  This  author  holds 
that  it  is  impossible  that  a  uterus  normal  in  position  can  be  forced 
out  of  the  pelvis  into  the  vagina.  As  long  as  the  uterus  is  in  its 
normal  antero-versio-flexio  position  abdominal  pressure  acts  upon 
its  posterior  wall  and  presses  the  body  upon  the  bladder.  The  portio 
vaginalis  under  increased  abdominal  pressure  has  a  tendency  to 
rise,  if  anything.  When,  however,  the  uterus  is  in  a  retroverted- 
retroflexed  position  its  vaginal  portion  becomes  dislocated  in  the 
direction  of  the  symphysis  pubis  and  moves  at  the  same  time  nearer 
the  pelvic  outlet.  The  uterus  and  its  cervix  now  lie  so  that  their 
axis  has  the  same  direction  with,  or  forms  the  continuation  of,  the 
axis  of  the  vagina.  Increased  intra-abdominal  pressure  can  now 
easily  force  down  the  uterus  into  the  vagina,  this  being  made  still 
easier  since  in  retro-versio-flexio  the  vaginal  portion  of  the  cervix 
is  nearer  the  pelvic  outlet  than  under  normal  conditions.  It  is  quite 
common  that  a  history  of  retro-versio-flexio  can  be  obtained  in  cases 
of  prolapsus.  The  reason  this  condition  is  most  frequently  found 
among  women  in  the  lower  walks  of  life  is  easily  explained.  Women 
of  the  better  classes,  as  a  rule,  when  retro-versio-flexio  leads  to  any 
symptoms,  seek  medical  aid  and  receive  the  proper  attention.  Women 
who  have  to  work  hard  for  a  living  often  find  no  time  to  consult 
the  physician,  and,  even  if  they  do,  they  can  not  submit  to  the  proper 
treatment  and  regimen  to  correct  the  retro-versio-flexio.  If  this 
goes  on  uncorrected  and  the  woman  suffering  from  it  is  performing 
hard  physical  work,  the  constant  exertions,  and  the  persistent  abdom- 
inal strain  in  consequence  thereof,  will,  in  a  large  percentage  of  cases, 
force  down  the  uterus  and  produce  descensus  and  prolapsus.  There 
are  also  some  cases,  however,  in  which  the  causation  of  the  affection 
may  be  different.  If,  after  childbirth,  the  vulva  remains  gaping  for 
too  long  a  time,  there  may  occur  a  prolapse  of  the  anterior  vaginal 


DISPLACEMENTS  OF   THE   UTERUS  319 

wall,  even  if  the  uterus  is  not  in  retro-versio-flexio,  and  this  may  be 
followed  by  prolapse  induced  by  the  persistent  traction  upon  the 
uterus  and  its  ligaments.  Prolapse  may  be  preceded  and  caused  by 
extensive  untreated  perineal  lacerations,  the  mechanism  of  causation 
being  the  same  as  just  indicated.  Another  set  of  conditions  which 
may  bring  about  prolapse  is  senile  changes  of  the  genitalia,  accom- 
panied by  atrophy  of  muscular,  and  disappearance  of  adipose,  tissue. 
A  factor  which  may  greatly  hasten  the  establishment  of  an  extensive 
prolapse,  if  the  other  conditions  are  favourable,  is  great  increase  in  the 
intra-abdominal  pressure  in  consequence  of  large  pelvic  tumours  or 
ascitic  accumulations.  In  prolapse  of  the  uterus  there  is,  of  course, 
present  a  prolapse  of  the  vagina.  The  upper  part  of  the  latter  is  either 
invaginated  into  the  lower  part,  or  the  whole  of  the  vagina  lies  inverted 
in  front  of  the  vulva.  Total  prolapsus  uteri,  however,  does  not  always 
mean  total  prolapse  of  the  vagina,  and  vice  versa.  Combined  with 
the  uterine  jDrolapse,  there  is  present  a  displacement  of  the  bladder 
(cystocele),  and  of  the  urethra.  Eectocele  may  be  present  but  is  usu- 
ally absent. 

The  patJiologic  changes  are  various.  That  such  a  malposition,  such 
a  complete  change  of  conditions  as  is  found  in  prolapsus  uteri,  is 
accompanied  by  grave  and  profound  anatomical  lesions,  is  self-evident, 
though  of  course  some  of  the  pathologic  changes  precede  instead  of 
follow  descensus.  Yery  marked  are  the  changes  of  the  lining  of 
the  inverted  vagina.  The  epithelia  become  dry  and  horny.  In  some 
places  the  epithelial  covering  is  thickened,  while  in  others,  particularly 
in  the  neighbourhood  of  the  external  os  of  the  cervix,  it  becomes 
thinned  out  and  is  entirely  lost,  so  that  ulcerations  appear  in  this 
neighbourhood.  These  changes  are  due  to  the  fact  that  the  inverted 
vagina  is  no  longer  moistened  by  the  cervical  secretion  but  is  exposed 
to  the  air  and  subjected  to  other  insults.  The  ulcerations  frequently 
show  sharp  margins,  or  they  present  clefts  caused  by  traction  upon 
the  changed  tissues.  There  is  generally  noticeable  a  hypertrophy  of 
the  prolapsed  parts.  It  is  most  marked  at  the  portio  vaginalis  uteri, 
but  is  also  well  seen  in  the  supravaginal  portion.  The  cervix  as  a 
whole  is  often  greatly  elongated  and  thickened  in  its  antero-posterior 
and  lateral  diameters  (Fig.  134).  The  uterine  body  is  likewise  en- 
larged, though  proportionately  to  a  lesser  degree.  In  women  advanced 
in  years,  the  enlargement  of  the  corpus  may  be  very  insignificant  or 
even  absent.  The  enlargement  of  the  uterus  is,  however,  not  so 
much  due  to  a  true  hypertrophy  as  to  an  extensive  oedema  caused  by 
circulatory  disturbances.  That  this  is  indeed  the  case,  is  proved  by 
the  observation  that  after  reposition  of  the  organ,  its  size  is  often  ma- 
terially decreased  in  a  very  short  time.  The  mucous  membrane  of  the 
uterus  in  prolapse  is  thick  and  succulent,  and  there  occurs  not  infre- 
quently an  endometritis  glandularis  h}qoertrophica.  The  higher  de- 
grees of  prolapse  being  usually  combined  with  prolapse  of  the  bladder, 
this  organ  likewise  shows  morbid  changes,  such  as  catarrhal  inflam- 


320 


A  TEXT-BOOK  OP  GYNECOLOGY 


mation  of  the  vesical  mucous  membrane,  or  inflammation  of  the  muscu- 
lar coat  which  may  even  lead  to  destructive  processes.  The  vesical 
inflammation  may  spread  by  continuity  to  the  ureters  and  the  pelves 
of  the  kidneys.     Klistner  in  a  case  of  prolapsus  uteri  saw  a  profound 

purulent  pyelitis 
which  ran  a  fatal 
course.  Inflamma- 
tory changes  of  the 
internal  sexual  or- 
gans, the  tubes  and 
ovaries,  and  the 
pelvic  peritoneum, 
are  quite  frequent  in 
prolapse.  Klistner, 
in  a  series  of  eighty 
cases  of  laparoto- 
mies, ventrofixa- 
tions,  and  plastic 
operations  on  the 
vagina  for  |)rolapse, 
carefully  examined 
the  internal  sexual 
organs  and  found 
that  in  almost  one 
half  of  them  chron- 
ic inflammatory  pro- 
cesses could  be  ob- 
served in  the  ova- 
ries, the  pelvic 
peritoneum,  and  the 
fimbriated  extremi- 
ties of  the  Fallopian 
tubes.  The  patho- 
logic conditions 
found  were  oophori- 
tis corticalis,  hy- 
drops folliculorum 
ovarii,  perimetritis, 
perisaljDingitis  with 
or  without  closure 
of  the  abdominal  end  of  the  tube,  and  hydrops  of  the  tubes.  The  same 
author  frequently  noticed  a  mild  degree  of  serous  infiltration  of  the  pel- 
vic peritoneum.  In  some  of  his  fatal  cases  of  prolapse  he  saw,  in  conse- 
quence of  profound  septic  infection  due  to  streptococci,  abscess  forma- 
tion in  the  subperitoneal  connective  tissue,  particularly  in  the  con- 
nective tissue  between  the  bladder  and  uterus.  Also  purulent  infil- 
tration of  the  muscular  coat  of  the  uterus,  abscess  of  the  ovary  and 


Fig.  134  (Martin). — "  The  cervix  as  a  whole  is  often  greatly 
elongated  and  thickened  in  its  antero-posterior  and  lateral 
diameters." — Heezog  (page  319). 


DISPLACEMENTS  OF  THE  UTERUS  321 

encapsulated  or  general  purulent  peritonitis.  (See  Pathology  of  Uter- 
ine Displacements.) 

The  symptoms  of  prolapsus  uteri  may  be  so  mild  in  the  earlier 
stages  as  easily  to  escape  attention,  or,  if  detected,  they  are  liable  to 
be  interpreted  as  indicating  a  less  important  condition  than  a  displace- 
ment of  the  uterus.  Pain  in  the  loins,  sacralgia,  increased  by  walking, 
prolonged  standing  or  overhead  work,  and,  particularly  by  straining  at 
defecation,  is  the  first  to  attract  attention.  This  pain  increases  as 
the  condition  advances  until  the  patient  becomes  conscious  of  what 
she  construes  to  be  a  foreign  body  in  the  vagina.  Pressure  by  the 
■descending  organ  is  liable  to  cause  vesical  and  rectal  tenesmus.  In  a 
.still  further  stage  of  development  the  cervix  presents  at  the  ostium 
vagina3,  or  the  entire  uteriis  may  protrude  externally  and  occupy  a 
position  between  the  thighs.  The  diagnosis  in  the  earlier  stages  is 
not  always  easily  made.  Patients  are  generally  examined  in  either  the 
recumbent  or  the  semiprone  (Sims's)  position — in  either  of  which,  but 
particularly  in  the  latter,  a  uterus  in  the  earlier  stages  of  descent  has 
a,  tendency  to  gravitate  into  its  normal  situation.  It  occasionally  hap- 
pens that  the  first  suggestion  of  an  existing  prolapse  is  derived  from 
the  fact  that  a  well-adjusted  tampon  is  being  unaccountably  extruded 
from  the  vagina.  This  fact  will  prompt  an  examination  of  the  patient 
in  the  standing  posture — provided  that  this  has  not  already  been  done, 
as  a  part  of  the  earlier  examination  of  the  case.  The  uterus  will  be 
found  to  have  descended  from  its  normal  plane  and  to  occupy  a  posi- 
tion of  relative  retroversion.  It  may  be  found  in  any  degree  of  de- 
scent. Complete  procidentia  may  be  mistaken  by  the  patient  herself 
for  cystocele  and  hydrocele,  bu.t  this  point  is  easily  cleared  up  by  care- 
ful examination.  A  uterine  polypus,  or  even  one  of  vaginal  origin, 
may  simulate  complete  procidentia  uteri.  The  diagnosis  is  cleared  up 
under  these  circumstances  by  careful  digital  examination,  with  par- 
ticular reference  to  detecting  the  location  and  condition  of  the  cervix. 
Bimanual  exploration,  by  determining  the  location  of  the  fundus  and 
the  size  of  the  uterus,  will  clear  iip  any  remaining  doubts.  Inversion 
has  been  mistaken  for  prolapsus  of  the  uterus,  but  the  history  of  the 
case,  the  existence  of  the  hemorrhage,  the  character  of  the  mucosa,  and 
the  existence  or  nonexistence  of  the  fundus  in  its  normal  relations  as 
determined  by  bimanual  examination,  will  lead  to  an  accurate  con- 
clusion. 

Treatment. — Conservative,  or,  more  properly  speaking,  the  nonsurgi- 
cal treatment  of  these  cases,  resolves  itself  into  medicinal,  hygienic,  and 
mechanical.  The  m,edicinal  treatment  consists,  for  the  most  part,  in 
the  administration  of  laxatives  to  overcome  the  constipation,  which,  in 
many  cases,  is  a  potent  factor  in  the  causation  of  the  trouble.  For  this 
purpose  saline  waters,  such  as  the  Hunyadi  Janos  or  the  Apenta,  should 
be  given  persistently  in  comparatively  small  doses  after,  but  not  be- 
forf,  meals.  If  given  before  meals,  they  will  cause  catharsis,  enerva- 
tioti  of  the  bowels,  and  consequent  aggravation  of  the  constipation; 
22 


322  A  TEXT-BOOK  OP  GYNECOLOGY 

but  if  given  after  meals  they  will  mingle  with  the  food,  and,  after  a. 
couple  of  days,  induce  normal  dejections  not  followed  by  serious  conse- 
quences. Hygienic  measures  consist  in  attention  to  all  the  secretory 
functions,  and  especially  avoidance  of  errors  in  diet.  Massage  of  the 
uterus  has  been  recommended,  and  as  a  remedy  for  relieving  passive 
engorgement  or  chronic  hyperplasia  it  is  of  value,  and  should  be 
employed  for  the  relief  of  prolapse,  especially  in  its  incipiency,  when- 
ever dependent  upon  these  conditions.  It  should  not,  however,  be 
employed  in  the  presence  of  acute  inflammation  of  either  the  uterus  or 
its  appendages.  Under  the  head  of  mecJianical  treatment  tamponade 
must  be  given  first  place.  This  should  be  practised  as  elsewhere  de- 
scribed in  this  volume.  If  tampons  saturated  with  some  astringent, 
agent  are  carefully  adjusted  they  will  give  excellent  mechanical  sup- 
port and  afi^ord  the  relaxed  ligaments  an  opportunity  to  regain  their 
strength.  Pessaries  are  employed  for  the  same  purpose  and  a  certain 
percentage  of  cures  is  realized  from  their  employment,  which,  how- 
ever, is  not  destitute  of  danger.  The  pessary  with  an  intrauterine  stem 
should  never  be  employed;  cup-pessaries  are  for  the  most  part  mis- 
chievous in  their  results,  and,  to  avoid  their  damaging  influence,  must 
be  frequently  removed.  The  martingale  ring  of  hard  rubber  may  keep 
the  uterus  within  the  pelvis,  but  it  does  so  by  distending  the  vagina, 
laterally  and  by  resting  upon  the  pelvic  floor.  The  inflated  soft-rubber 
pessary  has  an  even  better  power  of  retention,  but  it  is,  at  best,  a  dirty 
and  stinking  thing,  and  should  be  used  only  when  other  means  of 
treatment  are  not  available.  This  instrument  is  very  popular  with 
practitioners  because  of  the  facility  with  which  it  is  placed  and  the 
effectiveness  with  which  it  keeps  the  womb  from  dropping  out  of  the 
vulvar  orifice.  The  fact,  however,  is  generally  lost  sight  of,  that  this, 
pessary  never  cures  prolapsus  in  the  sense  of  restoring  the  uterus  to 
its  normal  position  and  keeping  it  there,  and  but  few  practitioners 
take  into  account  the  other  fact,  namely,  that  by  a  continuous  pressure 
upon  the  pelvic  floor  and  by  persistent  lateral  distention  of  the  vagina, 
this  instrument  has  a  tendency  really  to  aggravate  pre-existing 
troubles,  notwithstanding  the  fact  that  it  alfords  temporary  relief. 
The  soft-rubber  pessary  favours  germ  propagation  and  is,  therefore,  a. 
constant  menace  to  the  health.  The  best  device  among  pessaries  is 
Thomas's  retroversion  pessary  already  alluded  to.  If  carefully  ad- 
justed, it  affords  comfort  in  these  cases  and  its  use  is  sometimes  fol- 
lowed by  cure. 

The  surgical  treatment  of  downward  displacements  of  the  uterus- 
has  for  its  object  the  return  of  the  organ  to  its  natural  position  and 
its  retention  there  by  the  restoration,  so  far  as  possible,  of  its  normal 
anatomic  connections.  Any  treatment,  to  be  effective,  must  be  carried 
out  in  full  recognition  of  the  fact,  that  prolapse  of  the  uterus  commonly 
occurs  as  the  result  of  either  serious  lacerations  of  the  pelvic  floor  and 
the  perineum,  or  as  the  result  of  atrophy  and  relaxation  of  all  the 
uterine  supports.     The  final  result  is  the  same  in  each  case.     In  a 


DISPLACEMENTS   OF  THE  UTERUS  323 

limited  number  of  cases,  the  injuries  below  are  not  so  much  the  cause 
of  the  prolapse  as  the  great  relaxation  of  the  uterine  ligaments,  particu- 
larly the  utero-sacral.  No  prolapse  can  take  place  without  relaxation 
of  these  ligaments. 

The  first  step  in  a  prolapse  is  always  a  retroversion;  so  that  relaxa- 
tion of  the  round  ligaments  is  a  universal  accompaniment  of  this  con- 
dition. If,  with  the  relaxation  of  the  round  ligaments,  there  is  also 
relaxation  of  the  utero-sacral  ligaments,  then  the  uterus,  following  the 
axis  of  the  pelvis,  slowly  and  gradually  makes  its  way  downward  under 
the  influence  of  intra-abdominal  pressure,  until  it  finally  appears  at 
the  vulvar  orifice,  .and  may  eventually  be  forced  outside  the  patient's 
body.  These  being  the  causes  of  prolapse,  all  operative  procedures 
must  have  for  their  object  the  restoration  of  the  normal  supports  of 
the  body.  If  these  can  not  be  restored,  then  some  new  support  must 
be  sought.  With  the  object  of  relieving  the  downward  traction  on 
the  uterus,  operations  may  be  performed  on  both  the  anterior  and  pos- 
terior vaginal  walls.  Unquestionably,  the  best  operations  for  this 
purpose  are  those  devised  by  Sims  and  Emmet. 

Emmet's  Operation  upon  the  Anterior  Vaginal  Wall  (Anterior  Col- 
porrhaphy). — "  I  first  antevert  the  uterus  with  my  finger,  as  the  patient 
lies  on  the  back.  The  neck  of  the  uterus  is  then  kept  crowded  up 
into  the  posterior  cul-de-sac  by  a  sponge  probang  in  the  hands  of  an 
assistant,  while  the  patient  is  being  placed  on  the  left  side  for  the  intro- 
duction of  the  speculum.  I  then  endeavour  to  find  two  points,  one 
about  half  an  inch  from  the  cervix  on  each  side,  and  a  little  behind 
the  line  of  its  anterior  lip,  which  can  be  drawn  together  in  front  of  the 
uterus  by  means  of  a  tenaculum  in  each  hand.  When  two  such  points 
can  be  thus  brought  together  without  undue  tension,  forming  trian- 
gular-shaped folds,  the  surfaces  are  to  be  freshened.  One  of  the  te- 
nacula  must  be  securely  hooked  in  the  tissues,  to  indicate  the  point. 
Then,  one  hand  being  disengaged,  a  surface  half  an  inch  square  about 
the  point  of  the  other  tenaculum  is  to  be  denuded  with  a  pair  of 
scissors.  Next  a  similar  surface  is  to  be  freshened  around  the  point  of 
the  first  tenaculum,  and  a  strip  afterward  removed  from  the  vaginal 
surface,  in  front  of  the  uterus,  about  an  inch  long  by  half  an  inch 
wide."     (Emmet's  Gynecology,  third  edition.) 

A  ligature  of  catgut  is  then  passed  beneath  each  of  these  freshened 
surfaces,  which,  when  tied,  brings  them  all  together  in  front  of  the 
cervix,  with  the  effect  of  forming  a  fold  at  this  point.  There  are 
also,  upon  the  anterior  vaginal  wall,  two  folds  in  the  shape  of  an 
ellipse,  extending  from  the  surfaces  secured  in  front  of  the  uterus, 
nearly  to  the  vaginal  outlet.  These  folds  are  now  to  be  denuded, 
turned  in,  and  secured  with  a  continuous  catgut  suture.  The  stitches 
should  be  placed  about  a  quarter  of  an  inch  apart,  and  should  include 
a  libera]  amount  of  tissues.  The  patient  should  be  confined  in  a  re- 
cumbent position  for  two  or  three  weeks  after  the  operation,  until  the 
parts  are  firmly  united. 


324  ^  TEXT-BOOK  OF   GYNECOLOGY 

Following  this  operation,  or  at  the  same  sitting  if  thought  advisable, 
the  perineum  should  be  firmly  closed  by  Emmet's  method.  (See  Chap- 
ter on  Eupture  of  the  Perineum.) 

The  cervix  uteri,  if  lacerated  or  diseased,  should  be  closed  by  the 
operation  of  trachelorrhaphy,  or  amputated,  as  the  case  may  be. 

It  is  Mann's  belief  that  these  operations  alone  will  not  generally 
cure  permanently  a  bad  case  of  prolapse.  As  the  uterus  is  always 
retroverted  in  this  condition,  if  it  is  left  turned  back  it  will  remain  in 
the  axis  of  the  vagina,  and,  acting  as  a  wedge,  will  gradually  force  its 
way  down  and  out,  and  the  old  conditions  will  be  reproduced.  To  ob- 
viate this  condition,  it  will  be  necessary  to  restore  the  round  ligaments 
and  the  utero-sacral  ligaments.  In  this  way  the  cervix  can  be  kept 
up  in  the  hollow  of  the  sacrum  and  the  fundus  turned  forward.  If 
this  is  done,  the  uterus  will  be  at  nearly  right  angles  to  the  vagina, 
and  the  danger  of  a  return  of  the  prolapse  will  be  done  away  with. 

After  the  operations  upon  the  vaginal  outlet  the  patient  may  wear 
a  pessary,  which  takes  the  place  of  the  utero-sacral  ligaments,  and 
this  in  itself  may  be  enough.  If  not,  then  Alexander's  operation  may 
be  done  and  the  fundus  kept  forward  b}'  the  tightened  round  ligaments. 
All  idea  of  curing  a  prolapse  by  doing  Alexander's  operation  must  be 
laid  aside,  as  the  round  ligaments  alone  are  not  strong  enough  to  sus- 
pend the  uterus,  but,  in  a  very  short  time,  will  give  way  and  allow  a 
relapse.  In  very  bad  cases  where  the  uterus  is  greatly  enlarged,  and 
in  old  women,  in  whom  very  great  atrophy  of  the  parts  has  taken  place, 
all  these  procedures  are  apt  to  fail,  and  we  must  then  resort  to  ventral 
fixation,  as  already  suggested. 

The  removal  of  the  uterus  for  the  cure  of  prolapse,  in  the  opinion 
of  Mann  and  other  representative  gynecologists,  is  wrong.  It  is  not, 
in  his  view,  the  weight  of  the  uterus  merely  which  brings  it  down,  but 
the  relaxation  of  the  supporting  structures.  After  the  uterus  is  re- 
moved, the  vaginal  walls  will  come  do-^oi  as  badly  as  ever,  and  Mann 
has  seen  one  case  at  least  in  which  hysterectomj^  failed  to  cure,  the 
previously  existing  rectocele  and  cystocele  recurring  and  becoming 
worse,  until  a  complete  hernia  of  the  vagina  existed.  The  cure  of  this 
condition  is  exceedingly  difficult,  and  is  harder  than  before  removal 
of  the  uterus,  as  the  possibility  of  ventral  fixation  is  done  away  with. 

Inversion  of  the  Uterus. — Inversion  of  the  uterus  means  a  turning 
inside  out  of  that  organ,  and  consists  of  the  invagination  of  the  fundus 
into  or  through  the  cavity  of  the  womb.  This  form  of  displacement  is 
not  frequent;  Braun  and  Spaeth  report  that  not  a  case  of  complete 
inversion  of  the  uterus  has  occurred  in  250,000  births  in  their  clinics; 
while  it  has  been  observed  but  once  in  191,000  deliveries  in  the  Eo- 
tunda  Lying-in-Hospital  of  Dublin. 

The  causes  of  inversion  of  the  uterus  are  generally,  but  not  always, 
connected  with  parturition.  At  this  time,  when  the  uterus  is  enlarged 
and  its  walls  are  softened  by  the  ordinary  evolutional  changes  of  preg- 
nancy, but  two  additional  conditions  are  required  to  render  inversion 


DISPLACEMENTS  OF   THE  UTERUS  325 

probable^  viz.:  relaxation  of  the  uterine  wall  and  downward  traction 
upon  the  fundus.  This  traction  may  be  exercised  by  drawing  upon 
the  cord  in  a  case  of  fundal  implantation  of  the  placenta;  or,  given  a 
case  of  adherent  fundal  placenta,  the  involuntary  efforts  of  the  uterus 
to  expel  the  afterbirth,  may  cause  the  latter  to  drag  the  fundus  down- 
ward into  the  cavity,  or,  for  that  matter,  through  the  open  cervix  into 
the  vagina.  A  large  pedunculated  polypus  attached  to  the  fundus  of 
the  uterus  and  finally  expelled  by  that  organ  may,  by  persistent  trac- 
tion, induce  inversion  in  the  nonpregnant  uterus.  A  case  of  this 
kind  came  under  the  observation  of  Eeed.  Small  sessile  fibroids  have 
been  found  in  the  wall  of  the  inverted  uterus  and  have  been  construed 
as  causes  of  the  condition.  The  mechanism  of  inversion  in  these  cases 
has  been  explained  by  Treub,  who  states  (British  Gynecological  Journal) 
that  in  them  there  "  is  no  regular  contraction  of  the  uterine  wall  and 
that  there  can  not  be.  The  base  of  a  sessile  tumour  can  not  contract, 
because  of  the  implantation  of  the  tumour,  which  diminishes  or  alto- 
gether abolishes  the  contractility  of  that  part  of  the  wall,  and  it  can 
not  be  that  only  the  contractility  of  that  base  is  diminished;  the  sur- 
rounding parts  must  necessarily  be  feebler  within  a  greater  or  smaller 
circumference.  If  from  the  outset  the  tumour  was  intramural,  the 
smaller  degree  of  resistance  of  that  part  of  the  uterine  wall,  coupled 
with  intra-abdominal  pressure,  may  occasionally  bring  about  a  slight 
beginning  of  inversion.  And  when  this  is  the  case,  the  conditions 
are  essentially  the  same  for  sessile  and  intramural  tumours,  and  for  the 
partial  inversion  described  by  Rokitansky.  A  circle  of  uterine  tissue 
is  abruptly  curved  in  the  place  where  Eokitansky  found  the  external 
indentation.  I  need  hardly  say  that  in  that  incurved  circle  the  uterine 
muscle  must  be  absolutely  paralyzed.  And  this  paralysis  again  will  not 
be  confined  to  a  linear  circle,  but  gradually  diminishing  will  extend 
over  a  greater  or  smaller  surface.  The  contractions  of  the  normal  part 
of  the  uterine  wall  will  try  to  expel  the  part  of  the  wall  that  acts  as  a 
foreign  body.  These  expulsive  efforts  may  slightly  increase  the  inver- 
sion as  far  as  the  paralysis  surrounding  the  circle  of  inversion  permits, 
thus  displacing  the  circle  itself;  and  paralyzing  another  part  of  the 
uterine  wall.  Necessarily  the  extension  of  the  partial  paralysis  proceeds 
farther  in  the  uterine  wall,  too,  and  by  the  repeated  action  of  this  mus- 
cular play  the  inversion  may  gradually  become  complete  as  regards  the 
body  of  the  uterus.  As  soon  as  the  body  is  inverted,  there  is  no  longer 
any  excitement  for  uterine  contractions,  and  the  inversion  of  the  cervix 
generally  does  not  take  place.  And  it  is  the  intra-abdominal  pressure 
again  that  may  invert  the  cervix  too." 

Inversion  of  the  uterus  may  be  complete  or  incomplete;  in  the  for- 
mer case  the  organ  is  turned  completely  inside  out,  the  inverted  fundus 
and  body  of  the  uterus  lying  within  the  vagina  (Fig.  135),  or  protruding 
from,  the  vulvar  orifice.  The  condition  may  also  be  described  as  recent 
or  old,  acute  or  chronic,  the  one  type  being  represented  by  the  recent 
inversion  of  the  organ  with   its  attendant  alarming  symptoms;  the 


326 


A  TEXT-BOOK  OP  GYNECOLOGY 


other,  when  the  condition  either  complete  or  incomplete  has  occurred, 
involution  of  the  uterus  having  taken  place  after  the  occurrence  of 
the  displacement,  which  remains  in  a  chronic  and  more  or  less  perma- 
nent form. 

The  symptoms  of  inversion  of  the  uterus  following  parturition  con- 
sist, first,  in  profuse  hemorrhage  ensuing  upon  the  delivery  of  the 
placenta;  or,  when  the  fundus  is  drawn  down  by  the  still  adhering 

placenta    the     latter 
T^^^P^'W  may  be  peeled  off  by 

external  action,  and 
violent  hemorrhage 
ensue.  Physical  ex- 
amination should  be 
made  at  once  by  the 
bimanual  method. 
The  intra  -  vaginal 
finger  will  detect  a 
globular  mass,  pre- 
senting either  just 
without  or  just  with- 
in the  thoroughly  re- 
laxed cervix;  while 
the  hand  upon  the 
abdominal  wall  will 
readily  detect  the 
disapjoearance  of  the 
fundus  from  its  nor- 
mal site  with  the 
development  of  a  dis- 
tinct ring  at  the 
point  of  its  disap- 
pearance. In  an  in- 
teresting case  reported  by  Cordier  wherein  an  inversion  had  fol- 
lowed an  operation  for  the  removal  of  a  polypus,  the  symptoms  during 
the  next  few  months  were  those  of  frequent  yet  slight  discharge  of 
blood-stained  fluid  from  the  vagina;  there  were  no  menstrual  pains, 
nor  was  there  a  history  of  extrusive  contractions  of  the  uterus. 
Digital  examination  revealed  in  the  vagina  a  pyriform  mass  about  3 
inches  in  length  by  2.5  in  breadth,  of  a  soft  and  velvety  nature,  and 
not  painful  to  the  touch.  The  finger  could  be  carried  all  round 
the  mass,  which  disappeared  through  the  os  by  a  constricted  neck,  and 
could  be  swept  around  the  neck  of  the  mass  for  nearly  an  inch  within 
the  cervical  canal.  The  speculum  revealed  the  openings  of  the  Fallo- 
pian tubes,  on  the  presenting  aspect  of  the  mass.  A  probe  could  be 
easily  introduced  into  the  uterine  ends  of  the  tubes  under  vision  while 
the  speculum  was  in  position.  Such  appearances  as  the  foregoing, 
coupled  with  the  disappearance  of  the  fundus  from  its  normal  situa- 


FiG.  135. — "Inversion  of  the  uterus  may  be  complete  .  . 
the  .  .  .  fundus  and  body  .  .  .  lying  within  the  vagina.' 
— Eeed  (page  325). 


DISPLACEMENTS  OF   THE   UTERUS  327 

tion,  as  determined  by  bimanual  exploration,  comprise  the  essential 
diagnostic  criteria  in  these  cases. 

If  the  abdominal  wall  is  thick,  and  the  condition  of  the  uterus, 
particularly  in  nonparturient  or  in  chronic  cases,  can  not  be  outlined 
by  the  bimanual  maniiDulation,  the  index  finger  of  one  hand  should 
be  introduced  into  the  rectum  while  a  sound  is  passed  into  the  bladder; 
if  the  sound  and  the  finger  meet  above  the  presenting  tumour  the 
evidence  is  conclusive  that  inversion  exists. 

The  prognosis  of  inversion  of  the  uterus  is  never  favourable, 
although  A.  F.  Jones,  of  Omaha,  reports  a  case  of  spontaneous  reduc- 
tion of  an  inverted  uterus  three  years  after  the  occurrence  of  the  acci- 
dent. Crosse  studied  the  histories  of  nearly  400  cases,  with  the  result 
that  he  ascertained  the  mortality  from  this  condition  to  be  nearly  -35 
per  cent,  death  occurring  either  very  soon  after  the  accident  or  within  a 
month.  Of  109  fatal  cases,  the  fatal  termination  in  72  ensued  within  a 
few  hours,  and  in  the  majority  within  half  an  hour.  Eight  died  in  from 
one  to  seven  days  and  six  in  from  one  to  four  weeks.  After  the  first 
month  the  danger  is  slight,  but  it  begins  again  with  the  resumption 
of  menstruation,  which  has  a  tendency  to  become  hemorrhagic. 
Crampton's  table  {American  Journal  of  Obstetrics,  October,  1885)  re- 
veals the  fact  that  of  120  recent  cases,  87  recovered,  32  died,  1  remained 
unrelieved.  Twelve  of  the  cases,  however,  were  moribund  when  first 
visited.  In  the  fatal  cases,  reposition  was  usually  effected  readily 
enough,  but  too  late  to  save  life.  Of  104  chronic  inversions,  91  recov- 
ered, 7  died,  and  6  remained  unrelieved.  The  average  mortality  as 
shown  by  Crampton's  table  is  about  20  per  cent.  Pregnancy  may 
occur,  followed  by  normal  delivery,  in  cases  in  which  the  uterus  has 
been  inverted  and  has  either  reduced  itself  spontaneously  or  has  been 
reduced  by  operation. 

The  pathology  of  this  condition  is  by  no  means  distinct.  '\Ylien 
the  accident  occurs  in  the  puerperal  state  the  probably  one  essential 
factor  in  its  causation  is  uterine  inertia,  which  is  a  functional  rather 
than  an  organic  condition.  After  the  occurrence  of  pvierperal  inver- 
sion, the  womb,  if  left  in  position,  seems  to  undergo  the  ordinary 
course  of  involution.  Aside  from  the  malposition  there  seems  to  be 
no  special  pathologic  state  induced.  Treub,  of  Amsterdam,  made  a 
careful  microscopic  examination  of  a  uterus  which  he  removed  for 
nonparturient  inversion,  and  found  the  muscular  structure  normal 
with  absolutely  no  appearance  of  atrophy.  There  existed,  however,  a 
very  redematous  hypertrophy  of  the  exposed  mucous  membrane. 

The  treatment  of  inversion  of  the  uterus  differs  materially  in  acute 
and  in  chronic  cases.  In  acute  cases — i.  e.,  those  of  recent  occurrence — 
the  first  indications  are  to  secure  hemostasis  and  to  effect  reduction. 
The  hand  should  be  immediately  inserted  into  the  vagina  and  upward 
pressure  should  be  exercised  by  the  fingers  directly  against  the  centre  of 
the  protruding  mass,  while  counter  pressure  should  be  exercised  from 
above  by  a  hand  placed  against  what  may  now  be  designated  as  the 


328  A   TEXT-BOOK  OP  GYNECOLOGY 

cervical  ring.  It  is  better  to  conduct  the  intravaginal  manipulations 
under  a  current  of  water  heated  to  110''  F.,  or,  preferably,  water  and 
vinegar,  half  and  half,  brought  to  the  same  temperature.  Vinegar 
is  an  excellent  hemostatic  with  distinct  antiseptic  properties.  If  the 
fountain  syringe  or  other  reservoir  is  hung  very  high,  the  hydrostatic 
pressure  thereby  secured  becomes  an  additional  force  available  in  the 
work  of  reduction.  If  these  measures  do  not  at  once  control  the 
hemorrhage,  and  if  its  continuance  for  any  length  of  time  is  a  menace 
to  the  patient's  life,  an  elastic  band  should  be  placed  around  the  neck 
of  the  protruding  mass  and  should  be  left  iii  situ  for  several  hours.  It 
should  not  be  adjusted  so  tightly  as  to  induce  strangulation,  nor 
should  it  be  left  on  so  long  as  to  produce  destruction  of  the  tissue. 
When  it  is  unwound  the  hemorrhage  will  generally  be  found  to  have 
ceased,  in  wdiich  case  manipulations  looking  to  the  reduction  of  the 
organ  should  be  resumed.  Mechanical  repositors,  consisting  of  a 
staff  with  a  bulbous  extremity,  may  be  made  from  wood  or  other  ma- 
terial and  used  with  persistent  pressure.  Lawson  Tait  utilized  con- 
stant elastic  pressure,  which  he  applied  to  a  repositor  by  means  of  an 
elastic  perineal  belt  fastened  before  and  behind  to  an  abdominal  girdle. 
There  are  some  dangers  attached  to  this  method  of  treatment.  If  the 
intrauterine  extremity  of  the  repositor  is  not  very  blunt,  or  else  bulb- 
ous or  cup-shaped,  an  apparently  slight  elastic  pressure  may  be  suffi- 
cient to  force  it  through  the  soft  uterine  tissues.  Then,  too,  if  the 
repositor  with  a  large  bulb,  or  a  cuplike  intrauterine  end,  succeeds  in 
accomplishing  its  purpose,  the  instrument  itself  may  become  incar- 
cerated by  contraction  of  the  cervix.  AVhile  this  complication  is  by 
no  means  insurmountable,  it  has  proved  embarrassing.  If  the  extem- 
porized repositor  is  made  of  wood  or  other  porous  material,  it  may 
speedily  become  septic  and  a  consequent  source  of  extreme  danger. 
To  avoid  this  accident,  it  should,  if  conveniently  possible,  be  given 
two  or  three  coats  of  shellac  before  being  used. 

The  treatment  of  clironic  inversion  of  the  uterus  has  been  a  source  of 
great  perplexity  since  the  days  of  Hippocrates.  This  master  genius  de- 
scribed with  great  fidelity  the  condition  of  inversion,  which  he  treated 
by  placing  the  woman  on  her  back,  upon  a  couch,  elevating  her  feet, 
extending  her  legs,  and  applying  compresses  and  sponges  against  the 
tumour,  holding  them  in  place  by  means  of  a  perineal  bandage.  This 
was  kept  up  for  seven  days.  If  it  failed,  the  woman's  womb  was 
anointed,  she  was  fastened  by  her  heels  to  a  ladder  with  her  head  hang- 
ing down,  and  was  violently  shaken  with  the  object  of  thus  reducing 
the  displaced  organ.  Strange  as  it  may  seem,  Castex,  as  late  as  1859 
{Gazette  hebdomadaire  de  nicdecine  et  de  cliirurgie),  reported  the  success- 
ful adoption  of  this  Hippocratic  practice  by  a  Moorish  midwife  at 
Tangier.  The  condition  and  its  treatment  through  the  succeeding 
centuries  commanded  the  attention  of  Rhazas,  Avicenna,  Aretseus,  and 
Themison,  among  the  ancients. 

Various  modern  methods  have  been  devised  to  effect  the  reduction 


DISPLACEMENTS  OP   THE    UTERUS  329 

of  chronic  inversion  of  the  uterus.  White,  of  Buffalo,  as  long  ago  as 
1858,  published  a  plan  of  reduction  by  continued  pressure,  which  he 
applied  by  adjusting  the  soft  rubber  cup-shaped  end  of  a  repo.sitor 
against  the  presenting  fundus  of  the  uterus;  to  the  other  end  of  this 
repositor  a  spring  capable  of  maintaining  ten  pounds  pressure  was 
adjusted,  and  so  arranged  as  to  lie  against  the  breast  of  the  operator. 
Pressure  was  thus  exerted,  while  counter-pressure  was  made  by  the 
hands  against  the  cervical  ring,  the  pressure  being  exercised  through 
the  abdominal  wall.  This  method  was  modified  by  Tyler  Smith,  Ave- 
ling.  Wing,  Eobert  Barnes,  Lawson  Tait,  and  others,  but  with  no 
essential  deviation  in  principle. 

Carl  Braun,  in  1851,  introduced  a  method  of  reduction  by  vaginal 
tamponade  by  means  of  a  caoutchouc  bag  which  he  called  a  colpeuryn- 
ter.  When  this  bag  is  properly  adjusted  to  the  uterus,  the  latter  is 
pressed  upward  in  such  a  way  as  to  place  the  vaginal  attachments  upon 
the  stretch,  causing  them  to  draw  open  the  cervical  cavity  by  lateral 
tension,  thus  acting  not  only  as  a  dilator  but  as  a  repositor.  The 
same  principle  is  applied  to-day  by  many  practitioners.  Neugebauer 
utilizes  an  intravaginal  elastic  bag  which  is  gradually  distended  with 
water  from  a  high  plane.  The  hydrostatic  pressure  thus  induced  is 
found  to  be  effective,  a  case  in  which  the  inversion  had  existed  for  two 
years  having  been  thus  reduced  in  nineteen  days.  The  patient  suffered 
no  pain  and  learned  to  fill  and  empty  the  bag  herself  when  it  was 
necessary  to  relieve  the  pressure  upon  the  urethra. 

When  conservative  means  at  reduction  fail,  recourse  must  be  had 
to  surgical  intervention.  T.  Gaillard  Thomas  advised  an  operation  of 
forcible  dilatation  of  the  inverted  uterine  canal.  This  was  practised 
by  first  making  an  abdominal  section,  stretching  the  uterine  tissues 
by  means  of  a  strong  uterine  dilator,  and  then  reducing  the  uterus 
by  conjoined  manipulation.  The  mortality  following  this  operation  was 
large  and  it  has  been  practically  abandoned.  The  principle  involved 
in  Gaillard  Thomas's  operation,  viz.,  the  forcible  dilatation  of  the 
inverted  uterine  canal,  has  been  so  modified  as  to  avoid  the  necessity 
of  the  preliminary  abdominal  section.  This  modification  consists  in 
drawing  down  the  uterus  carefully  enveloped  about  its  neck  with  some 
sterilized  gauze.  An  incision  is  then  made  through  either  the  anterior 
or  the  posterior  uterine  wall,  and  through  this  incision  a  dilator  is 
introduced.  When  the  dilatation  has  been  carried  to  a  suflicient  de- 
gree, as  determined  by  the  introduction  of  the  finger  through  the 
operation  wound  and  through  the  now  dilated  cervical  canal,  the 
incision  is  sewn  up  with  sterilized  catgut  and  the  fundus  is  forced  back 
into  position.  Kehrer  (Centralhlatt  fur  Gyndhologie)  draws  the  in- 
verted uterus  down  to  the  entrance  of  the  vagina  and  makes  an  incision 
on  its  anterior  surface  through  the  whole  length  of  the  cervix  from 
the  OS  externum  to  a  little  beyond  the  middle  of  the  corpus,  and  ex- 
tending directly  tbi'ough  into  the  peritoneal  cavity.  The  wound  is 
then  stitched   from  l,lie  fundus  to  the  os  internum,  after  which  the 


330  A  TEXT-BOOK  OF   GYNECOLOGY 

inversion  is  reduced,  when,  finally,  the  lower  part  of  the  wound  is 
sewn  up  as  far  as  the  os  externum. 

Hirst  operates  by  dividing  the  posterior  cervical  wall  as  far  up 
as  may  be  necessary  to  gain  space  through  which  to  effect  the  reduc- 
tion, which  he  has  been  able  to  do  without  making  the  extensive  inci- 
sion of  Kehrer.  After  the  uterus  has  been  restored  by  Hirst's  method, 
the  only  remaining  step  consists  in  applying  a  few  interrupted  sutures 
to  the  incised  posterior  lip.  This  operation  impresses  one  as  being  at 
once  simple  and  effective. 

Vaginal  hysterectomy  as  a  remedy  for  chronic  and  irreducible 
inversion  of  the  uterus  is  not  a  modern  conception.  Themison  sug- 
gested it  B.  c.  50,  but  it  was  not  adopted  in  practice  until  Soranus,  of 
Ephesus,  amputated  an  inverted  uterus  about  the  end  of  the  second 
century  of  our  era.  The  suggestion  has  been  recognised  as  one  of 
practicability  from  that  day  until  the  present.  In  its  adoption  the 
general  principles  of  technique  should  be  observed  that  are  outlined  in 
the  chapter  on  vaginal  hysterectomy. 

In  view  of  the  fact  that  the  inverted  uterus,  when  once  restored, 
is  capable  of  exercising  the  functions  of  reproduction,  vaginal  hyster- 
ectomy should  not  be  performed  in  child-bearing  women. 


CHAPTEE    XXV 
INJURIES   OF,   AND   FOREIGN   BODIES   IN,   THE  UTERUS 

Injuries:  (a)  parturient;  rupture,  laceration  of  the  cervix — Trachelorrhaphy  (Em- 
met)— Amputation  of  the  cervix — (b)  nonparturient ;  wounds  from  external 
causes — Foreign  bodies. 

Injuries  of  the  uterus  divide  themselves  naturally  into  (a)  par- 
turient, and  (b)  nonparturient. 

Rupture  of  the  uterus  is  an  accident  of  parturition.  It  may  be 
complete  or  incomplete.  In  the  latter,  the  injury  is  restricted  to  the 
muscularis  while  the  peritoneum  remains  intact.  This  was  regarded 
by  Lusk  as  more  likely  to  occur  in  lateral  tears  at  the  site  of  the  folds 
of  the  broad  ligament — though,  owing  to  the  relatively  loose  attach- 
ment of  the  peritoneum  at  the  lower  segment,  incomplete  ruptures 
are  not  necessarily  confined  to  those  points.  In  the  complete  form 
the  tear  extends  through  the  muscularis  and  the  peritoneum,  making, 
usually,  a  communicating  wound  with  the  abdominal  cavity,  although 
lacerations  have  occurred  in  that  zone  of  the  uterus  which  lies  in 
normal  attachment  to  the  bladder. 

The  causes  of  rupture  of  the  uterus  may  be  summarized  by  saying 
that  they  may  consist  of  any  condition  that  interferes  with  the  descent 
of  the  child,  that  favours  the  ascent  of  the  body  and  fundus,  or  dimin- 
ishes the  normal  powers  of  resistance  of  the  uterine  walls.  A  mon- 
strosity, a  hydrocephalic  head,  neglected  shoulder  presentation,  are 
examples  of  causes  that  may  exist  in  the  foetus.  Fibroid  tumours,  dis- 
tortion of  the  pelvis,  and  malignant  disease  of  the  cervix,  are  among 
the  maternal  causes.  Some  writers  have  placed  emphasis  upon  fatty 
degeneration  of  the  uterine  parenchyma  as  a  demonstrated  cause  of 
this  condition. 

The  mechanism  by  which  u.terine  ruptures  are  caused  was  first 
satisfactorily  explained  by  Bandl.  He  explained  that  in  normal 
labour  the  contractions  of  the  uterus  resulted  in  a  thickening  of  the 
fundus  and  body,  while  the  lower  segment  was  stretched  and  thinned 
by  the  downward  pressure  exercised  by  the  presenting  part  of  the 
fcetus.  This  process  was  strictly  physiologic,  so  long  as  no  obstacle 
existed  to  interfere  with  the  descent  of  the  child.  The  natural  result 
of  this  dilatation  was  the  practical  conversion  of  the  uterus  and  vagina 
into  a  continuous  canal.  When  labour  was  advanced,  the  lower  circum- 
ference of  the  body  of  the  uterus  was  ordinarily  distinguished  from 

331 


332  A   TEXT-BOOK  OF   GYNECOLOGY 

the  stretched  lower  segment  by  the  ridge  induced  by  the  contractions^ 
and  now  known  as  the  ring  of  Bandh  This  ring  was  ordinarily  found 
in  the  neighbourhood  of  the  pelvic  brini^  but  its  development  was 
proportionate  to  the  difficulty  of  the  labour.  In  the  presence  of 
some  obstruction  to  the  normal  descent  of  the  child,  the  retentive 
force  exercised  by  the  suspensory  ligaments  of  the  uterus  resulted  in 
the  upward  retraction  of  the  fundus  and  body  of  that  organ.  This  up- 
ward migration  of  the  superior  zone  of  the  uterus  resulted  in  a  cor- 
responding upward  migration  of  the  contraction  ring,  or  the  ring  of 
Bandl.  The  ascent  of  this  ring  deprived  the  lower  segment  of  the 
uterus  of  those  accessions  to  its  volume  and  resistant  force,  which, 
under  normal  circumstances,  would  be  derived  from  the  natural  dilata- 
tion of  the  ring  of  Bandl.  As  a  consequence,  the  lower,  or  cervical, 
structures  became  stretched  and  thin,  often  to  a  degree  that  they  could 
no  longer  maintain  their  integrity  against  the  exi^ulsive  and  divulsive 
force  from  within.  In  this  way,  according  to  Bandl's  explanation, 
the  majority  of  all  ruptures  of  the  uterus  begin  in  the  lower  segment, 
a  philosophic  conclusion  which  is  amply  confirmed  by  clinical  observa- 
tion. The  view  has  been  urged  that,  while  ruptures  of  the  uterus,  for 
the  reasons  already  given,  generally  begin  in  the  lower  segment  and 
extend  upward,  their  further  extension  toward  the  fundus  is  arrested 
by  the  action  of  the  now  migrated  ring  of  Bandl,  which,  in  certain 
cases,  may  be  felt  through  the  abdominal  walls  above  the  pubis,  or, 
even  as  high  as  the  umbilicus.  Many  of  the  ruptures  reported,  indi- 
cate that  a  tear  probably  started  in  the  lower  segment  of  the  uterus, 
and  extending  upward  part  way  to  the  fundus,  had  been  deflected  to 
one  side  or  the  other.  This  was  manifested  in  two  cases  by  Eeed. 
{New  York  Medical  Journal,  November  9,  1889.) 

The  symptoms  of  rupture  of  the  uterus,  when  partial,  may  consist 
of  only  an  evanescent  and  not  severe  shock,  a  temporary  interruption 
of  the  pains,  and  a  persistence  of  hemorrhage  after  delivery.  When 
the  rupture  is  complete,  however,  the  phenomena  induced  by  the 
accident  are  striking  and  immistakable.  There  is  profound  shock; 
the  uterine  contractions  and  pain  cease  instantly;  the  presenting  part 
of  the  child  recedes;  the  fundus  of  the  uterus  tilts  to  one  side,  or 
entirely  disappears  in  the  presence  of  a  new,  strange,  and  indefinite 
tumefaction  within  the  abdomen;  a  bloody  discharge  makes  its  appear- 
ance; and  frequently  there  is  prolapse  of  the  funis.  A  careful  exam- 
ination at  this  time  will  indicate,  not  only  a  recession  of  the  presenting 
part  of  the  child,  but  an  apparent  atony  of  the  cervical  structures.  If 
the  child  has  escaped  into  the  abdominal  cavity,  the  hand  is  intro- 
duced without  difficulty  into  the  uterus,  and  may,  in  certain  cases,  be 
carried  through  the  rent  in  the  uterus  into  the  peritoneal  cavity.  The 
diagnosis,  according  to  Ludwig,  is  not  always  easy,  even  when  the  fore- 
going symptoms  are  taken  into  account.  He  has  found  the  best  diag- 
nostic sign  to  be,  (a)  in  lateral  rupture,  the  interruption  of  the  natural 
contour  of  the  uterine  quadrant,  when  either  a  projection  or  a  nodule 


INJURIES  AND   FOREIGN  BODIES  OP   THE  UTERUS  333 

is  formed;  (&)  suddenly  acquired  abnormal  mobility  of  the  uterus;  and 
(c),  a  sign  upon  which  he  places  great  emphasis,  viz.,  emphysematous 
crackling  at  the  seat  of  rupture.  If  the  head  presents  and  can  be 
pushed  back,  the  bimanual  examination  under  deep  narcosis  makes  the 
diagnosis  certain. 

The  treatment  of  rupture  of  the  uterus  is  to  be  directed  to  the 
saving  of  the  life  of  both  the  mother  and  child,  when  possible.  If  the 
child  is  yet  within  the  uterine  cavity,  the  vertex  presenting,  forceps 
should  be  applied  without  delay;  if  breech  or  shoulder  is  presenting 
and  the  child  is  known  to  be  alive,  version  may  be  practised.  If  the 
child  is  still  within  the  uterine  cavity  but  is  known  to  be  dead,  it  may 
be  delivered  by  craniotomy,  morcellement,  or  by  any  other  means  that 
will  most  speedily  empty  the  uterine  cavity.  After  delivery  the 
uterine  cavity  should  be  carefully  explored,  and,  if  the  rupture  is  found 
to  communicate  with  the  peritoneal  cavity,  an  abdominal  section 
should  be  done  at  once.  If  rupture  has  been  complete  and  has  been 
followed  by  the  escape  of  the  child  into  the  ]3eritoneal  cavity,  the  child 
should  be  delivered  by  abdominal  section.  The  same  course  is  to  be 
followed  when  the  child  has  been  delivered  per  vias  naturales,  and  the 
placenta  has  escaped  into  the  abdominal  cavity — indeed  it  may  be 
adopted  as  a  safe  rule  that  the  abdominal  cavity  should  be  opened 
whenever  rupture  of  the  uterus  can  be  demonstrated  to  be  complete, 
no  matter  what  may  or  may  not  have  passed  through  the  rent.  This 
conclusion  is  based  upon  the  fact  that  although  neither  the  child  nor 
the  placenta  may  have  escaped  into  the  abdominal  cavity,  complete 
rupture  could  not  occur  without  the  escape  into  the  peritoneal  cavity 
of  either  blood,  amniotic  fluid,  or  other  products  of  gestation,  liable 
to  be  either  the  bearers  or  the  sources  of  infection.  The  abdomen 
should  in  such  cases  be  opened  and  thoroughly  washed  out  with  normal 
salt  solution.  If  hemorrhage  is  in  progress,  it  should  be  controlled 
either  by  the  application  of  forceps  to  the  broad  ligaments,  far  enough 
down  to  control,  not  only  the  ovarian,  but  the  uterine  arteries;  or  by 
an  elastic  ligature  temporarily  applied  below  the  site  of  rupture.  The 
treatment  of  the  uterus  at  this  point  is  one  of  extreme  importance. 
The  rent  may  be  closed,  which  is  best  done  by  paring  the  edges,  and 
approximating  and  closing  them  by  the  seroserous  suture,  adopted  by 
Czerny  and  Lembert,  in  Csesarean  section  (see  Csesarean  Section);  or 
the  uterus  may  be  removed,  converting  the  procedure  essentially  into 
a  Porro  operation.  Unless  there  is  extensive  destruction  of  the  tissues 
of  the  uterus,  with  obvious  infection,  its  removal  is  not  justifiable. 
Women  who  have  sustained  rupture  of  the  uterus  and  who  have  been 
successfully  operated  upon  by  closure  of  the  tear,  have  subsequently 
borne  children.  Deutsch  {C entralhlatt  fiir  Gyndhologie,  November 
14,  1889)  reported  a  case  of  symmetrically  contracted  pelvis  in  which 
rupture  of  the  uterus  had  been  treated  by  abdominal  section  four  years 
previously.  The  patient  went  to  term,  when  examination  revealed  the 
uterus  adherent  to  the  abdominal  wall,  causing  a  marked  projection 


334  ^  TEXT-BOOK  OF  GYNECOLOGY 

of  the  abdomen.  The  foetus  being  found  to  be  living,  the  patient  was 
narcotized,  the  os  was  dilated,  and  a  living  child  was  delivered  by  po- 
dalic  version.  If  carcinoma  or  fibroids  are  either  the  underlying  cause 
or  the  associated  condition  of  a  rupture  of  the  uterus,  no  hesitancy 
about  its  ablation  need  be  entertained.  The  operation  should  be 
done  as  soon  after  the  condition  is  detected  as  necessary  preparations 
can  be  made.  The  possibility  of  hemorrhage  and  the  still  greater  pos- 
sibility of  infection  make  it  imperative  that  intervention  should  be 
practised  as  speedily  as  possible.  Patients  may,  however,  live  for  a 
considerable  time  after  the  occurrence  of  this  accident,  even  without 
treatment.  Thus  St.  Braunwas,  of  Cracow,  reports  a  case  in  which 
he  had  extracted  the  foetus  by  abdominal  section  six  weeks  after  it 
had  escaped  through  a  rupture  of  the  uterus  into  the  peritoneal  cavity. 
The  foetus  was  bathed  in  pus,  which  filled  the  cavity  of  the  abdomen. 
The  patient,  of  course,  died  from  chronic  sepsis.  In  cases  in  which 
abdominal  section  is  practised,  the  operation  proper  should  be  both 
preceded  and  followed  by  free  administration  of  normal  salt  solution, 
either  by  intravenous  injection  or  by  hypodermoclysis. 

Lacerations  of  the  cervix  occur  chiefly  as  accidents  of  childbirth — 
although  latterly  they  are  encountered  in  occasional  instances  as  re- 
sults of  forcible  dilatation  of  the  cervix.  (See  Dilatation  of  the  Cer- 
vix.) When  this  operation  is  performed  with  too  much  rapidity  and 
by  one  of  the  powerful  instruments  now  in  use,  the  divulsion  may 
result,  not  merely  in  the  separation  of  submucous  fibres,  but  even  in  a 
complete  severance  of  continuity  of  the  cervical  tissue.  It  may  be 
said  that  laceration  of  the  cervix,  when  occurring  as  the  result  of  for- 
cible dilatation  or  of  parturition,  is  always  caused  by  divulsion  carried 
to  a  point  beyond  the  resistant  power  of  the  cervical  structures.  Lac- 
erations of  the  cervix  may  be  either  superficial  or  deep,  extending  as  far 
up  as  the  cervico-corporeal  Junction,  and  are,  in  reality,  but  examples 
of  rupture  of  the  uterus,  the  damage  occurring  in  the  lower  segment 
of  that  organ  and  involving  the  cervical  margin.  More  than  one  rup- 
ture of  this  kind  may  occur  at  once,  occasioning  what  is  spoken  of  as 
multiple  or  stellate  laceration  of  the  cervix.  When  lacerations  occur 
chiefly  within  the  cervical  canal,  but  do  not  extend  entirely  through 
to  the  lateral  vaginal  surfaces  of  the  cervix,  they  may  result  in  a 
permanent  enlargement  of  that  canal.  The  attention  of  the  profes- 
sion was  first  called  to  the  pathologic  character  of  these  injuries  by 
Emmet,  who  devised  the  operation  for  their  repair.  (See  Trache- 
lorrhaphy.) 

The  pathology  of  lacerations  of  the  cervix  relates  chiefly  to  ante- 
cedent and  subsequent  changes.  The  antecedent  changes  consist  of 
those  modifications  of  the  cervical  structure — e.  g.,  fatty  degeneration 
and  oedema — occurring  during  the  course  of  pregnancy,  which  result 
in  a  loss  of  the  normal  elasticity  of  the  tissues.  The  subsequent 
changes  relate  to  those  interferences  with  involution,  and  those  modifi- 
cations of  local  nutrition,  which  are  caused  by  the  tear,  and  the  con- 


INJURIES  AND   FOREIGN  BODIES   OF   THE  UTERUS  335 

sequent  interference  with  the  circulation.  After  the  receipt  of  the 
injury,  laceration  of  the  cervix  rarely  if  ever  heals  spontaneously. 
Eepair  occurs  by  process  of  cicatrization;  the  tissue  thus  formed  subse- 
quently contracts;  and  the  underlying  cervical  structures  are  distorted. 
When  the  laceration  is  bilateral  the  resulting  contraction  of  the  cica- 
tricial tissue  causes  a  retraction  outward  of  the  cervical  lips,  with  con- 
sequent e version  of  the  mucous  membrane.  The  mucous  membrane 
itself,  exposed  on  the  everted  surfaces  of  the  cervix,  presently  under- 
goes glandular  hypertrophy,  giving  to  the  unpractised  eye  the  appear- 
ance of  ulceration,  and  abounding  in  granulations.  There  is  no  doubt 
that  many  of  the  so-called  "  ulcerations  of  the  womb,"  treated  in  the 
years  gone  by  with  repeated  applications  of  lunar  caustic,  were,  in 
reality,  but  eversions  of  the  endocervix  in  a  state  of  glandular  hyper- 
trophy. The  enlarged  follicles  of  the  cervical  mucosa  manifest  an 
augmentation  of  function  corresponding  with  their  abnormal  develop- 
ment; and,  as  a  consequence,  the  cervix  is  always  covered  in  such  cases 
with  a  clear  viscid  mucus,  sometimes  tinged  with  blood.  Changes  in 
the  parenchyma  of  the  cervix  are  equally  marked  and  may  present  two 
extremes,  namely,  atrophy  or  hyperplasia.  When  the  laceration  is 
comparatively  superficial,  the  resulting  inflammation  goes  through  all 
the  consecutive  stages  from  preliminary  engorgement  to  final  atrophy; 
but  when  the  laceration  is  deep  and  the  consequent  cervical  eversion 
is  pronounced,  tliere  is  so  much  mechanical  interference  with  the 
circulation,  particularly  upon  the  venous  side,  that  passive  engorgement 
ensues,  resulting  finally  in  an  actual  increase  of  the  tissue  elements. 
This  state  of  hypertrophy  is  sometimes  associated  with  oedematous  in- 
filtration; but,  as  a  rule,  there  occurs  an  organization  of  the  adventi- 
tious tissue  elements  with  consequent  enlargement  and  induration  of 
the  cervix.  These  changes  may  be  more  pronounced  in  some  parts  of 
the  cervix  than  in  others,  the  difference  being  determined  by  the 
location,  depth,  and  consequent  infiuence,  of  the  laceration.  The  body 
and  fundus  of  the  uterus,  being  largely  supplied  with  blood  by  the 
ovarian  artery,  and  being  drained  by  the  ovarian  veins,  are  not  subject 
to  the  infiuences  arising  in  the  injury  of  the  cervix.  It  is  noticeable, 
however,  notwithstanding  the  fact  that  the  upper  zones  of  the  uterus 
possess  a  practically  independent  circulation,  that  they  undergo  the 
post-parturient  involutional  changes  tardily  in  the  presence  of  deep 
injuries  of  the  cervix.  Glandular  hypertrophies  are,  consequently, 
not  uncommon  in  these  cases  in  the  corporeal  endometrium.  (See 
Endometritis.)  The  inflammations  producing  this  increase  in  tissue, 
both  glandular  and  parenchymatous,  are  manifestly  dependent  in  a 
large  degree  upon  mechanical  disturbances  of  the  pelvic  circulation; 
but,  from  the  facts  that  lacerations  of  the  cervix  never  heal  without  at 
least  superficial  bacterial  invasion,  and  that  infection  once  established 
at  the  seat  of  laceration  readily  extends  upward,  these  inflammations 
must  be  recognised  as  infectious  quite  as  much  as  traumatic. 

Symptoms  of  laceration  of  the  cervix  at  the  time  of  its  occurrence 


336  A  TEXT-BOOK   OF   GYNECOLOGY 

may  be  absolutely  nil.  The  absence  of  all  symptoms  indicating  lacera- 
tion of  the  cervix  accounts  for  the  fact  that  the  majority  of  these  acci- 
dents are  never  discovered  until  long  after  their  occurrence,  when  the 
patient  presents  herself  for  treatment  for  vague  and  indefinite  pelvic 
symptoms.  In  occasional  instances,  however,  the  laceration  is  so  deep, 
■extending  up  to  and  involving  the  circular  artery,  that  hemorrhage 
results.  This  symptom  is  often  overlooked  for  a  time  under  the  im- 
pression that  the  flow  of  blood  is  nothing  more  or  less  than  that  which 
occurs  in  normal  cases  following  delivery.  When,  however,  this  hemor- 
rhage persists  for  a  considerable  time,  imparting  an  arterial  tinge  to 
the  otherwise  dull-coloured  lochia,  it  becomes  the  occasion  for  a  local 
examination.  Digital  exploration  at  this  time,  particularly  if  done 
by  an  inexperienced  operator,  is  liable  to  be  negative,  if  not  misleading, 
in  its  results.  The  cervix  during  the  first  few  days  following  delivery 
is  enlarged,  dilated,  oedematous,  and  flabby;  its  normal  contour  can 
not  be  detected,  while  superficial  abrasions,  or  even  deep  lacerations, 
can  not  be  distinguished  by  the  touch.  Under  these  circumstances  the 
patient  should  be  placed  in  the  Sims  position,  the  perineum  should  be 
retracted,  and  the  cervix  should  be  drawn  down  and  carefully  inspected, 
when  the  bleeding  point,  if  within  the  area  of  a  laceration,  can  be 
detected  and  controlled.  In  the  later  stages  of  a  laceration — i.  e.,  sev- 
eral weeks  or  months  after  delivery — there  is  vastly  less  difficulty  in 
detecting  the  actual  conditions.  The  patient  may  or  may  not  com- 
plain of  23ain.  Cicatricial  dej)osits,  particularly  in  the  angle  of  lacera- 
tion, and  especially  in  cases  of  long  standing,  may  impinge  upon  ter- 
minal nerve  filaments  and  occasion  severe  distress,  and  that  not  only 
in  the  uterus,  for  through  its  intimate  nerve  connections  with  both 
the  sympathetic  and  cerebro-spinal  systems,  this  relatively  slight  local 
injury  may  cause  a  widespread  perturbation  of  nerve  function.  It 
would  seem  in  certain  cases,  as  if  the  cervix  under  these  circumstances 
were  a  sort  of  central  telegraphic  office,  with  radiating  lines  over  which 
morbific  impulses  are  telegraphed  to  the  remotest  parts  of  the  system. 
Erratic  behaviour  of  the  apparatus  of  accommodation,  eccentric  dis- 
turbances of  hearing,  evanescent  or  persistent  turgescences  of  the  turbi- 
nates, congestions  of  the  Schneiderian  membrane,  asthmatic  disturb- 
ances, localized  variations  of  cutaneous  sensibility,  and  that  congeries 
of  nerve  perturbations  designated  as  hysteria,  have  been  known  to  fol- 
low in  the  wake  of  this  accident  and  to  have  been  cured  by  repair  of 
the  cervix.  These  so-called  reflex  symptoms,  however,  never  occur 
with  that  degree  of  constancy  necessary  for  them  to  be  accepted  as 
indications  of  an  existing  laceration  of  the  cervix.  It  may  be  said  in 
short  that  there  are  no  symptoms  of  a  subjective  character  that  are 
pathognomonic  of  this  condition.  Local  examination  alone  detects 
the  condition,  which  has  existed,  possibly,  for  years,  without  being 
suspected,  either  by  the  patient  or  her  medical  adviser.  Introduction 
of  the  finger  into  the  vagina  will  reveal  the  cervix  with  an  irregular 
contour;  it  may  be  multilobular,  each  lobule  being  divided  by  a  distinct 


INJURIES  AND  FOREIGN   BODIES  OP   THE  UTERUS  337 

iissure  (stellate  laceration),  or  it  may  be  divided  into  an  anterior  and  a 
posterior  lip  (bilateral  laceration),  or  it  may  be  fissured  upon  only  one 
side  (single  laceration).  If  examined  by  the  speculum,  these  appear- 
ances may  be  much  modified;  as,  for  instance,  if  a  bivalve  speculum 
is  employed,  its  dilatation  will  result  in  stretching  farther  apart 
the  antero-posterior  lip  of  the  cervix  in  a  bilateral  laceration;  indeed, 
in  cases  of  long  standing  in  which  the  eversion  has  become  pro- 
nounced, the  retracted  lij)s  may  have  been  drawn  up  to  the  utero- 
vaginal junction,  and,  when  distended  by  means  of  a  bivalve  speculum, 
the  marginal  contour  of  the  cervix  may  entirely  disappear.  The  pic- 
ture presented  in  the  speculum  will  be  that  of  a  double,  elliptical,  area 
of  apparent  erosion.  This  will  be  nothing  more  or  less,  in  practically 
every  case,  than  the  hypertrophic  endocervium.  If,  now,  this  patient  is 
placed  in  the  Sims  posture,  the  perineum  retracted,  and  the  retractor 
intrusted  to  an  assistant,  the  examiner  may,  by  means  of  a  volsella 
placed  in  the  apex  of  each  lip,  draw  the  severed  portions  of  the  cervix 
into  api^roximation.  He  will  thus  be  enabled  to  determine  the  depth 
and  other  exact  characters  of  the  laceration. 

The  complications  of  laceration  of  the  cervix  are  worthy  of  con- 
sideration. They  naturally  coexist  with  atrophies,  hypertrophies,  or 
hyperplasias  of  both  the  parenchyma  and  endometrium.  As  already 
indicated  when  considering  the  pathology  of  this  lesion,  bacterial  in- 
fection of  the  laceration  takes  place  at  the  time  of  its  occurrence;  pro- 
gressive invasion,  either  of  the  contiguous  mucous  surfaces  or  of  the 
opened  lymph  spaces,  ensues;  the  result  being  either  infection  and 
enlargement  of  the  pelvic  lymphatic  glands,  with  possible  resulting 
suppuration,  or  infection  with  purulent  accumulation  in  the  Fallopian 
tubes,  involving  the  ovaries  in  the  general  pathologic  processes.  These 
complications  are  frequently  encountered  and  are  directly  traceable  to 
the  original  injury  for  their  causation.  It  not  infrequently  happens 
that  laceration  is  not  detected  until  an  examination  is  demanded  for 
symptoms  of  carcinoma.  This  disease,  indeed,  exists  as  a  frequent 
complication  of  laceration,  the  carcinomatous  process  in  many  in- 
stances having  its  origin  in  the  cicatricial  covering  of  a  cervical  tear. 
Fibroids  and  other  neoplasms  may  coexist  with  laceration  of  the 
cervix. 

The  treatment  of  laceration  of  the  cervix  consists  essentially  in 
restoring  that  structure,  so  far  as  possible,  to  its  normal  state.  The 
steps  by  which  this  may  be  accomplished  must  vary  according  to  the 
pathologic  conditions  present  in  the  case;  thus,  if  the  case  is  one 
simply  of  laceration  without  marked  tissue  changes,  the  treatment  will 
consist  in  revivifying  the  margins  of  the  wound  and  approximating 
them  by  sutures;  if,  however,  there  is  extensive  liypertrophy,  it  may 
be  necessary  to  remove,  at  least,  a  part  of  the  enlarged  segment  of 
the  uterus.  At  the  same  time,  associated  pathologic  states  in  the 
endometrium  must  be  appropriately  treated. 


338 


A   TEXT-BOOK  OP   GYNECOLOGY 


Instruiinents  for 

Catheter,  glass 1 

Curette,  dull 1 

Sharp  (Sims's  modified) 1 

Martin's 1 

Recamier's 1 

Dilators,  difEerent  sizes 3 

Hegar's,  three  sizes. 

Forceps,  hemostatic,  two  of  each  size.   6 

Long  dressing 1 

Rat-tooth  dressing  2 

Bullet 2 

Needles,  assorted  sizes 8 


Trachelorrhaphy 

Needle  holders 2 

Nozzles,  glass  or  Edebohls's  hard  rubber  1 

Retractor,  small 1 

Intermediate 2 

Scalpels 2 

Scissors,  straight 1 

Shot  compressor  and  shot. 

Sound,  uterine 1 

Speculum,  Sims's  small 1 

Simon's,  with  handles  and  four  blades  1 

Tenaculum,  straight 1 

Tenacula,  curved 2 


Trachelorrhaphy,  or  the  operation  for  repair  of  the  lacerated  cervix, 
is  conveniently  clone  as  follows:  The  patient  is  placed  in  the  dorsal 

l^osition,  her  buttocks  at  the  edge  of  the 
operating  table,  her  knees  well  drawn  up, 
her  flexed  legs  being  intrusted  either  to 
an  assistant  or  to  the  efficient  mechanical 
attachments  of  the  modern  operating 
table.  A  Jones's  perineal  retractor  with 
a  short  blade  is  now  inserted  and  the  pos- 
terior lip  of  the  cervix  is  seized  with  a 
self-locking  volsella  and  is  drawn  down. 
Newman  has  devised  an  excellent  reverse- 
acting,  self -locking  volsella  (Fig.  136) 
which  on  being  inserted  into  the  cervical 
canal  and  expanded,  becomes  fixed  in  the 
uterine  tissues.  The  instrument  is  an  ex- 
ceedingly convenient  one,  as  its  shaft  lies 
along  the  mucous  track  of  the  cervical 
canal  and  becomes  a  convenient  guide, 
both  in  denuding  the  surfaces  and  in  pass- 
ing the  sutures.  The  downward  traction 
on  the  uterus  must  be  judiciously  regu- 
lated, force  beyond  a  few  pounds  never 
being  exercised.  Whenever  distinct  and 
sudden  resistance  is  experienced  in  effect- 
ing the  temporary  prolapse  of  the  uterus, 
it  is  to  be  construed  as  an  evidence  of 
adhesions,  and  is  a  danger  signal  admon- 
ishing the  operator  against  more  forcible 
traction.  When  the  uterus  is  thus  drawn 
down,  the  endometrium,  if  the  seat  of 
T.      .„^     ,^-r  1       ,    .    ,     glandular  hypertrophy,   should  be  vigor- 

FiG.  136. — "Newman  has   devised      °  ^^  i  iiii 

an  excellent  reverse-acting,  self-      0"Llsly     Curetted,     the     mUCUS,     blood,     and 

locking  volsella."— Reed.  debris,  being  carefully  washed  away  with  a 


INJURIES  AND   FOREIGN   BODIES   OF   THE   UTERUS  339 


jet  of  bichloride  water,  after  which  the  surface  is  dried  and  painted 
with  pure  carbolic  acid.     The  next  step  consists  in  denuding  the  sur- 
faces  to   be   approximated.      Their  respective   areas   should   be    defi- 
nitely determined  in  advance  by  making  a  preliminary  approximation. 
The  denudation  may  be  accomplished 
either  by  a  knife  or  by  scissors,  prefer- 
ably the  former.    A  very  good  knife  for 
the  purpose  is  that  devised  by  ISTew- 
man  (Fig.  137)  and  its  sharp  point  is  so 
arranged  that  it  can  be  easily  passed 
through  the  cervical  tissue  in  the  upper 
angle  of  the  laceration.     It  is  a  good 
rule  to  begin  the  denudation  by  first 
outlining  with  the  edge  of  a  bistoury 
the  tissues  to  be  removed.     These  may 
then  be  cut  away,  leaving  two  equal, 
denuded,       approximating       surfaces. 
Great  care  should  be  taken  to  remove 
the  deposit  of  cicatricial  tissue  from 
the  upper  angle  of  the  laceration.     In 
the  case  of  a  bilateral  laceration,  all 
the  surfaces  to  be  approximated  must 
be  denuded  before  the  work  of  sutur- 
ing is  begun.     The  sutures  may  be  in- 
serted by  means  of  a  short,  heavy,  de- 
tached needle,  which  is  employed  by 
means  of  a  needle  holder;  or,  they  may 
that   devised    by    be  inserted  by  means  of  an  obliquely 
Newman."— Keed.    curved  needle  such  as  that  used  by  Reed 
(Fig.    138).      The    sutures   themselves 
should  be  of  nonabsorbable  material.     Emmet  does  this 
operation  with  a  silver  wire,  and  annealed  iron  wire 
is  employed  by  some  operators.     As  a  rule,  however, 
the  silkworm  gut  is  the  material  of  preference.    Which- 
ever material   is   employed,   careful   antiseptic   precau- 
tions should  be  taken.     Catgut  has  been  used  with  suc- 
cess since  the   process  of  preparing  it  with  formalin 
and  boiling  it  has  been  perfected;    it  generally  lasts 
fourteen  days,  which  is  long  enough,  while  the  facility 
with  which  the  external  and  unabsorbed  remnants  are 
removed  is  a  point  in  its  favour.     The  suture  should 
be  passed  beneath  and   on  a  level  with   each   surface 
to  be  approxim.ated,  as  illustrated   (Fig.   139).     Two, 
three,    or    even    four,    sutures    may    be    required    upon    either    side, 
the  number  being  governed  by  the  depth  of  the  laceration.     After 
all   of  them  have   been   passed   the   volsella   may   be   removed,   the 
remaining  traction  on  the  uterus  being  exercised  by  means  of  the  ends 


Fig.   137.—"  A  very 
good  knife  ...  is 


Fig.  138. 
An      obliquely 
curved    needle 
used  by  Eeed." 
— Eeed. 


340 


A  TEXT-BOOK  OP   GYNECOLOGY 


of  the  sutures  on  one  side  being  gathered  together  in  a  forceps.  The 
surface  of  the  wound  should  be  irrigated  and  removed  by  means  of 
sterilized  water.  If  there  is  no  pulsating  hemorrhage,  no  further  atten- 
tion need  be  given  to  hemostasis  which  will  be  effected  by  the  approxi- 
mation of  the  surfaces 
and  the  pressure  of  the 
sutures.  The  sutures  are 
tied,  beginning  upon  one 
side  at  the  upper  angle, 
care  being  taken  that,  as 
they  are  tightened,  the 
underlying  margins  of 
the  tissues  are  brought 
into  accurate  coaptation. 
Care  should  be  taken  to 
avoid  tying  the  sutures 
too  tightly,  as  tissue  ne- 
crosis may  thereby  be  in- 
duced and  the  success  of 
the  operation  be  com- 
promised in  consequence. 
After  being  twisted,  if 
silver  wire  is  used,  or 
tied,  if  other  material  is 
employed,  the  distal  ends 
should  be  cut  off  about  an 
inch  from  the  knot,  and 
so  arranged  as  to  avoid 
causing  mechanical  irri- 
tation of  the  parts.  The 
sutures,  if  of  nonabsorb- 
able material,  should  be  left  in  situ  for  about  ten  days,  antiseptic 
vaginal  irrigation  being  practised  twice  daily  during  the  entire 
time.  To  remove  the  sutures,  the  patient  should  be  placed  in  the 
Sims  position  and  each  suture  seized  with  long-fixation  forceps  and 
subjected  to  gentle  traction.  The  loop  of  the  suture  will  thereby 
be  drawn  up  so  that  the  point  of  a  scissors  blade  may  be  easily  in- 
sinuated beneath  it.  It  is  important  that  the  stitches  should  be  re- 
moved under  inspection,  for,  if  the  effort  is  made  to  remove  them  by 
the  sense  of  touch  alone,  there  is  a  likelihood  of  cutting  both  ends  of  the 
loop  near  the  knot,  leaving  the  loop  itself  buried  in  the  tissues.  It  is 
true  that  this  is  not  a  matter  of  any  serious  moment,  but  it  may  occasion 
annoying  local  infection;  and  the  escape  of  a  loop  of  suture  material  at 
some  subsequent  time  is  always  construed  by  the  patient  as  a  more  or 
less  serious  reflection  upon  the  surgeon. 

Amputation  of  the  cervix,  in  whole  or  in  part,  is  demanded  for 
hypertrophic  and  hyperplastic  conditions  that  are  sometimes  associated 


Fig.  139. — "  The  suture  should  be  passed  beneath  and 
on  a  level  with  each  surface  to  be  approximated." — 
Eeed  (page  339). 


INJURIES  AND   FOREIGN   BODIES   OF  THE    UTERUS  341 

with  and  result  from  lacerations.  Emmet  {Transactions  of  the  American 
Gynecological  Society,  1897)  believes  that  these  conditions  should  be 
subjected  to  preliminary  local  treatment,  consisting  of  douches,  elimi- 
native  tamponade,  alterative  topical  applications,  or  even  local  deple- 
tion by  puncture.  Treatment  of  this  kind  may,  in  some  cases,  so  far 
reduce  hypertrophy  that  amputation  or  excision  is  unnecessary.  When, 
however,  the  desired  reduction  in  the  volume  and  consistence  of  the 
tissues  is  not  realized  by  such  conservative  treatment,  Emmet's  opera- 
tion of  amputation  may  be  adopted.  He  first  draws  the  uterus  down 
by  gentle  and  steady  traction  to  the  vaginal  outlet,  always  taking  care 
to  avoid  a  Jerking  movement  which  would  be  liable  to  rupture  some 
blood  vessel,  especially  if  there  has  been  a  pre-existing  intrapelvic  in- 
flammation. The  cervix  is  steadily  held  by  an  assistant  just  within 
the  vaginal  outlet,  for  at  this  point  the  arteries  will  be  placed  suffi- 
ciently on  the  stretch  to  lessen  their  calibre,  and  thus  to  render  the 
operation  to  a  great  extent  bloodless.  Care  is  taken  to  accurately  deter- 
mine the  line  of  vaginal  junction,  since  the  bladder  will  be  entered  in 
front  and  the  peritoneal  cavity  behind,  if  an  attempt  is  made  to  remove 
what  seems  to  be  the  cervix  over  which  a  mass  of  thickened  vaginal  tis- 
sue has  been  crowded.  In  those  cases  in  which  atrophy  takes  place  as 
already  described  in  this  chapter,  the  field  of  operation  can  not  be  a 
large  one  at  the  beginning.  An  incision  is  now  made  round  the  cervix 
near  the  vaginal  juncture;  the  subsequent  dissection  should  be  made 
by  cutting  always  toward  the  centre  as  a  precaution  against  entering 
the  bladder  and  the  peritoneal  cavity,  and  with  the  object  of  removing 
a  cone-shaped  piece  of  tissue.  As  the  operation  advances,  the  excava- 
tion must  continually  be  drawn  up  to  the  vaginal  level  so  that  the 
operator  may  have  the  parts  under  observation  and  the  bleeding  under 
control.  As  each  blood  vessel  is  divided,  the  neighbouring  tissues 
should  immediately  be  seized  by  an  assistant  and  held  as  a  fresh  point 
for  traction,  when  the  vessels  will  promptly  retract  and  cease  to  bleed. 
The  cervix  is  to  be  removed  segment  by  segment  until  underlying 
healthy  tissue  is  reached.  The  most  efficient  instrument  for  this 
purpose  is  the  pointed  scissors  which  Emmet  devised  nearly  thirty  years 
ago  for  clearing  out  the  angles  in  the  operation  for  laceration  of  the 
cervix.  After  having  removed  the  tissues  in  the  manner  just  de- 
scribed, nonabsorbable  sutures  are  inserted;  Emmet  employs  the  silver 
wire.  The  sutures  are  inserted  antero-posteriorly.  Those  to  either 
side  of  the  cervical  canal  are  inserted  (Fig.  140)  through  the  posterior 
lip,  into  the  excavation,  into  the  tissued  at  the  fundus  of  the  excava- 
tion, out  again,  and  then  through  the  anterior  lip  of  the  wound.  The 
sutures  that  are  passed  coincidently  with  the  cervical  canal  are  intro- 
duced through  the  posterior  lip  of  the  wound,  out  again,  in  again 
through  the  posterior  lip  of  the  cervical  canal,  and  out  through  the 
cervical  canal.  Another  suture  is  passed  similarly  to  the  last,  through 
the  lip  formed  by  the  anterior  wall  of  the  cervical  canal,  out  again  and 
through  the   anterior   lip   of   the   cervix.     As   many  antero-postei'ior 


342 


A   TEXT-BOOK  OF  GYNECOLOGY 


sutures  are  passed  transversely  to  the  cervical  canal  as  may  be  required. 
"  If/^  says  Emmet,  "  we  follow  the  course  of  either  of  these  sutures  it  • 
will  be  apparent  that  when  the  front  suture,  for  instance,  is  twisted, 
the  free  vaginal  surface  must  be  drawn  over  the  stump,  and  as  the  edge 
of  the  uterine  canal  is  a  fixed  point,  the  former  will  be  secured  at  that 
point,  and  a  similar  effect  will  be  produced  posterior  to  the  cervical 
canal  when  the  posterior  suture  has  been  twisted  in  the  same  manner. 
The  result  of  thus  securing  these  sutures  will  be  that  the  edge  of  the 
divided  mucous  membrane  on  the  vaginal  surface,  front  and  back,  will 

be  rolled  over  in  contact 
with  the  edges  of  the 
uterine  canal,  and  when 
primary  union  has  taken 
place  the  natural  calibre 
of  the  passage  must  be 
preserved.  But  before 
securing  these,  or  any  of 
the  sutures,  as  many  as 
may  be  deemed  necessary 
should  be  first  introduced 
on  each  side  of  the  cervi- 
cal canal.  Here  the  loose 
vaginal  edge  is  first 
caught  up,  and  then  the 
needle  is  made  to  include 
a  sufficient  portion  of  the 
uterine  stump  on  a  line 
with  and  lateral  to  the 
uterine  canal,  and  in  turn 
it  should  take  up  the 
vaginal  tissue  behind. 
The  only  difficulty  is  in 
catching  up  enough  of 
the  uterine  tissue  in  the 
centre  of  the  stump  to 
hold  it  firmly  in  contact 
with  the  flaps  after  the 
sutures  have  been  secured.  But  this  difficulty  can  be  overcome  by 
using  a  properly-shaped  needle  with  the  pointed  end  slightly  bent  on 
itself.  The  passage  of  the  needle  is  greatly  facilitated  by  snipping 
with  pointed  scissors  a  sulcus  in  the  tissues  at  a  sufficient  depth  in 
front  of  the  advancing  needle,  and  from  the  bottom  of  this  cut  its 
point  should  be  brought  out  to  pass  over  to  secure  the  vaginal 
edge. 

"  After  all  the  silver  sutures  have  been  twisted  it  will  be  made 
evident,  by  the  introduction  of  a  uterine  sound  for  half  an  inch,  that 
the  canal  has  been  left  fully  open,  and  it  will  be  seen  at  the  same  time 


Fig.  140. — "  Those  to  either  side  of  the  cervical  canal 
are  inserted  through  the  posterior  lip,  into  the  exca- 
vation, into  the  tissues  at  the  fundus  of  the  excava- 
tion, out  again,  and  then  through  the  anterior  lip  of 
the  wound." — Eeed  (page  341). 


INJURIES  AND  FOREIGN  BODIES  OF   THE   UTERUS  343 

that  the  vaginal  tissues  have  been  drawn  over  the  stump  and  firmly 
secured  to  its  surface. 

"  At  the  completion  of  the  operation  it  is  necessary  that  the  uterus 
.should  be  carefully  replaced  with  the  finger  to  its  natural  position,  and 
it  must  be  done  without  displacing  the  ends  of  the  sutures,  which  have 
been  carefully  bent  down  on  to  the  vaginal  surface.  As  soon  as  the 
uterus  is  replaced  in  its  normal  position  the  lateral  traction  then 
exerted  in  the  vagina  will  keep  the  vaginal  covering  in  close  relation 
with  the  stump. 

"  No  surgical  operation  with  which  I  am  familiar  yields  a  more 
uniform  and  satisfactory  result  than  this  one,  when  performed  under 
the  following  conditions:  The  proper  use  of  silver  sutures,  keeping 
the  patient  in  bed  for  three  weeks  after  the  operation  including  the 
menstrual  period  when  possible,  and  not  removing  the  sutures  before 
the  nineteenth  or  twentieth  day,  when  the  parts  will  have  become 
firmly  united  and  the  uterus  greatly  reduced  in  size." 

Vesico-uterine  Fistulse. — These  fistula  are  of  two  kinds.  In  one 
form  the  cervix  is  partially  destroyed,  and  in  the  other  form  the  fistu- 
lous opening  occurs  into  the  cervical  canal  and  is  so  concealed  that  the 
cervix  must  be  split  during  any  operation  for  its  obliteration.  These 
fistulas  can  only  take  place  in  the  cervix. 

It  is  imjjortant  that  a  diagnosis  should  be  made  in  these  cases  dis- 
tinguishing between  a  vesico-uterine  fistula  and  a  uretero-uterine  fistula. 
In  each  case  the  urine  is  discharged  from  the  os  uteri.  Sometimes  a 
probe  can  be  passed  through  the  fistulous  opening  from  the  bladder 
into  the  cervical  canal  or  vice  versa.  Clear  fluids  injected  into  the 
bladder  will  come  out  of  the  os  uteri.  If  continued  pressvire  is  kept 
Tip  in  the  cervical  canal  no  acute  nephydrosis  will  occur  if  the 
iistula  is  vesico-uterine  and  not  uretero-uterine.  The  electric  cysto- 
scope  should  be  of  great  assistance.  With  it  one  should  be  able  to 
make  out  any  perforation  of  the  bladder  wall,  and  thus  to  distinguish 
between  vesical  and  ureteral  fistulse.  (See  Examination  of  the 
Bladder.) 

Prognosis.— -These  fistulge  oftentimes  heal  very  kindly  owing  to 
the  fact  that  the  thick  wall  of  the  uterus,  during  the  process  of  heal- 
ing, is  likely  to  close  the  opening. 

Treatment. — The  treatment  is  the  same  as  that  for  vesico-vaginal 
fistula,  namely,  closure  by  suture.  Each  of  these  cases  must  be  judged 
upon  its  own  merits  and  the  operator  must  think  out  for  himself  his 
exact  method  of  procedure.  If  the  main  principles,  previously  stated, 
are  adhered  to,  he  will,  in  all  probability,  meet  with  success.  If  the 
fistula  is  situated  close  to  the  cervix  the  anterior  lip  may  be  made  use 
of  to  close  tbe  opening.  If  a  great  deal  of  the  anterior  lip  has  been 
destroyed  it  will  then  be  necessary  to  use  the  posterior  lip,  and  if  this  is 
done  the  menstrual  fluid  will  be  discharged  into  the  bladder  and  out 
through  the  urethra.  It  is  unfortunate  to  have  this  happen  and  if 
possible  it  should  be  avoided. 


344 


A   TEXT-BOOK  OF   GYNECOLOGY 


Fig.   141. 


-"  The   bladder,  thus  separated,  should   be   drawn 
down  with  a  forceps  or  volsella." — Keed. 


Reed's  Operation  for  Vesico-uterine  Fistula, — The  condition  is 
best  controlled  by  a  free  incision,  dividing  the  uterus  from  the  blad- 
der, just  as  is  practised  in  the  preliminary  step  of  vaginal  hysterec- 
tomy. The  bladder, 
thus  separated,, 
should  be  drawn 
down  with  a  forceps 
or  volsella  (Fig. 
141);  the  fistula  will 
then  be  brought  into 
clear  view  and  can 
be  closed  by  a  double 
line  of  continuous 
catgut  sutures.  If 
the  fistula  opens  di- 
rectly into  the  ute- 
rus (Fig.  142),  the 
latter  should  be  curetted  and  packed  and  a  single  suture  should  be 
placed  across  the  orifice  of  the  fistula  as  it  presents  at  the  denuded 
anterior  uterine  surface.  If  the  fistula  traverses  the  uterus  longi- 
tudinally and  opens  at 
the  cervical  margin  (Fig. 
143),  a  curved  director 
should  be  inserted  and 
the  uterine  tissues  split 
up  to  the  point  of  en- 
trance of  the  fistula.  If 
the  tract  has  become 
cicatricial  it  should  be 
carefully  dissected  out, 
and  the  place  that  it  for- 
merly occupied  should  be 
closed  by  repeated  inter- 
rupted sutures.  In  split- 
ting up  the  uterine  tis- 
sues, the  circular  artery 
is  more  than  likely  to 
be  divided.  The  hemor- 
rhage may  be  somewhat 
difficult  to  control.  This, 
however,  is  best  done  by 
passing  a  deep  suture  e7i 

masse  to  either  side  of  the  incision,  so  situated  as 
severed  ends  of  the  artery  within  its  grasp. 

Both  the  bladder  and  the  uterus  having  been  thus  repaired,  the 
parts  should  be  brought  into  apposition  and  closed  by  interrupted 
sutures.     The  vagina  should  be  packed  with  antiseptic  gauze  and  the 


142. — "  The  tistula  opens  directly  into  the  uterus." 
— Eeed. 


to  embrace  the 


INJURIES  AND  FOREIGN  BODIES  OP   THE   UTERUS 


345 


usual  precautions  observed  during  convalescence.  The  most  notable  of 
these  precautions  is  the  introduction  and  retention  of  a  sigmoid  cathe- 
ter during  several  days  after  the  operation.  The  evacuation  of  the 
bladder,  either  by  catheter  oi'  spontaneously,  at  intervals  of  not  more 
than  three  hours  during  the  succeeding  week  should  be  rigorously 
practised. 

Wounds  of  the  uterus  from  external  causes  are  of  occasional  oc- 
currence. The  injudicious  use  of  the  uterine  sound  sometimes  re- 
sults in  perforation  of 
the  walls  of  that  organ. 
Cases  of  this  kind  have 
been  recorded  by  Law- 
son  Tait  and  others.  If 
the  instrument  is  aseptic 
the  accident  is  rarely 
followed  by  serious  con- 
sequences; if,  however, 
infection  ensues,  death 
may  follow.  The  intro- 
duction into  the  uterus 
of  catheters,  sounds,  and 
bougies  for  the  purpose 
of  inducing  criminal 
abortion,  generally  re- 
sults in  more  or  less  in- 
jury to  the  endometri- 
um, if  not  to  the  deeper  structures  of  the  wound.  Injuries  of  this  kind, 
when  inflicted  by  unclean  instruments,  result  in  those  deaths  from 
constitutional  sepsis  which  occur  so  frequently  in  the  annals  of  crime. 
There  is  probably  nothing  more  dangerous  to  a  woman  than  an  effort, 
particularly  on  her  own  part,  to  induce  abortion  by  intrauterine  instru- 
mentation. In  many  cases  of  perforation  of  the  uterine  wall  by  the 
sound,  at  the  hands  of  experienced  operators,  the  diseased  condition 
of  the  uterus  itself  is  responsible  for  the  accident.  The  walls  of  the 
uterus  are  very  nonresistant  in  all  inflammatory  conditions,  but  par- 
ticularly so  in  the  presence  of  puerperal  infection.  In  ordinary  cases 
of  subinvolution,  the  uterine  tissue  is  very  friable.  When  the  walls 
of  the  uterus  are  soft  and  a>dematous  as  the  result  of  a  flexion  at  an 
acute  angle,  the  muscularis  is  easily  penetrated;  and  the  same  is  triie 
when  the  organ  is  the  seat  of  malignant  disease,  such,  for  example,  as 
sarcoma,  syncytioma  malignum,  and  adenoma  malignum.  Under  these 
circumstances  the  uterus  is  sometimes  perforated  by  means  of  a  curette, 
many  of  these  instruments  being  so  constructed  that  they  ofi'er  no  safe- 
guard against  the  accident.  Gau,  of  Cincinnati,  has  devised  an  ex- 
cellent curette  with  a  safety  point  and  edge  calculated  to  prevent  acci- 
dents of  this  character  (Fig.  144).  The  diagnosis  of  uterine  perforation 
is  not  difficult.     Perforation  may  be  suspected  whenever  the  sound  or 


Fig.  143. — "  The  fistula  traverses  the  uterus  longitudi- 
nally and  opens  at  the  cervical  margin."  —  Eeed 
(page  344). 


346 


A  TEXT-BOOK  OP   aYNECOLOGY 


curette  j)enetrates  farther  than  the  previously  ascertained  limits  of  the 
uterus.  The  treatment  consists  in  quietude  and  vigilance.  In  a  septic 
case  it  may  be  prudent  to  await  the  development  of  menacing  symptoms, 
which,  as  soon  as  they  occur,  should  prompt  the  surgeon  to  extirpate 
the  uterus.  Intrauterine  injections  are  to  be  carefully  avoided,  even 
when  administered  by  means  of  a  recurrent  syringe,  for  the  reason 
that  any  force,  however  slight,  may  be  sufficient  to  carry  infectious 
material  from  the  uterus  into  the  peritoneal  cavity.  In  some  cases 
the  injury  inflicted,  particularly  by  the  curette,  may  cause  an  opening 
which  may  result  in  the  protrusion  either  of  omentum  or  of  a  loop  of 
intestine.  In  the  presence  of  this  complication  the  protruding  struc- 
ture should  be  replaced  and  the  uterine  cavity  packed  pending  the 
completion  of  preparations  for  hysterectomy,  which  should  be  done 

as  promptly  as  j)ossible.  In  cases  in  which 
injury  has  occurred  to  the  intestines,  as 
rarely  happens  from  either  the  sound  or 
the  curette,  an  abdominal  section  should 
be  done  at  once. 

Gunshot  wounds  of  the  uterus,  particu- 
larly when  pregnant,  are  recorded.  Ben- 
brook  {Medical  Times)  relates  an  interest- 
ing case  of  this  sort,  in  which  a  44-calibre 
pistol  ball  passed  in  just  below  the  crest 
of  the  ilium  going  downward  and  back- 
ward, and  a  second  one  entered  the  ab- 
dominal cavity  from  a  point  between  the 
eighth  and  ninth  ribs.  Three  days  later, 
the  woman  was  taken  with  hemorrhage 
from  the  uterus  associated  with  labour 
pains,  and  resulting  in  the  expulsion  of  a 
quantity  of  blood  clot  together  with  a  bul- 
let, which  had  passed  into  the  cavity  of  the  uterus  through  the  fundus. 
Another  case  by  Eobinson  {Lancet)  revealed  the  fact  that  a  ball  had  en- 
tered the  abdomen  a  little  to  the  right  and  below  the  umbilicus;  an  hour 
later  labour  set  in,  resulting  in  the  instrumental  delivery  of  a  dead  child 
near  full  term,  with  a  gunshot  wound  in  its  right  shoulder.  The  ball 
was  found  in  the  debris.  The  mother  made  an  uninterrupted  recovery. 
Metert  records  {Medical  Review)  an  interesting  case  of  a  self-inflicted 
gunshot  wound  in  the  abdomen  of  a  pregnant  woman,  the  ball  passing 
through  the  uterus  and  the  arm  of  the  child,  an  abdominal  section 
being  followed  by  the  recovery  of  the  mother.  G-unshot  wounds  gen- 
erally occur  either  at  the  fundus  or  the  anterior  wall  of  the  uterus. 
Their  infliction  is  followed  by  pronounced  shock  and  collapse,  pain 
in  the  abdominal  region,  at  first  located  at  the  site  of  injury,  but 
presently  becoming  diffuse,  while  symptoms  of  peritonitis  of  the  dif- 
fuse form  shortly  manifest  themselves.  In  the  course  of  a  few  hours 
pains  with  rhythmic  contractions  of  the  uterus  occur,  whether  in  the 


Pig.  144. — "  Gau  has  devised  an 
excellent  curette  with  a  safety 
point  and  edge." — Keed. 


INJURIES  AND   FOREIGN   BODIES   OP   THE    UTERUS  34Y 

impregnated  or  the  nonimpregnated  uterus.  In  either  instance  the 
organ  is  more  or  less  distended;  in  the  first  by  the  products  of  con- 
ception, and  in  the  latter  by  clots.  The  gravid  uterus  in  many  cases 
throws  off  its  contents,  a  fact  which  does  not  in  the  least  diminish  the 
necessity  for  prompt  intervention.  As  to  treatment,  it  may  be  laid 
down  as  a  rule  that  every  case  of  perforating  wound  of  the  abdomen 
of  a  jDregnant  woman  would  be  subjected  to  an  exploratory  abdominal 
section  without  reference  to  symptoms.  The  probability  of  perforation 
of  the  uterus  and  of  the  consequent  escape  of  amniotic  fluid  and 
blood  into  the  peritoneal  cavity,  makes  it  imperative  that  intervention 
should  be  both  prompt  and  thorough.  The  fact,  also,  that  in  these 
eases  the  womb  and  its  contents  act  as  a  sort  of  shield  to  the  intestines, 
saving  them  from  injury,  increases  the  prospects  of  the  mother  and 
forms  an  additional  reason  for  speedy  intervention.  The  character 
and  extent  of  the  operation  must  be  determined  by  the  conditions 
revealed  by  the  exploratory  incision.  If  there  has  been  extensive 
destruction  of  uterine  tissue,  offering  no  reasonable  prospect  of  recov- 
ery, with  the  uterus  m  situ,  hysterectomy  should  be  done.  This  rule 
applies  whether  the  uterus  has  been  emptied  or  not.  All  debris  should 
be  washed  from  the  abdominal  cavity  by  copious  irrigation  with  normal 
salt  solution,  and  intravenous  injection  or  hypodermoclysis  should  be 
practised  in  the  presence  of  the  generally  pronounced  shock,  or  when- 
ever there  has  been  a  free  loss  of  blood.  If  the  gravid  uterus  has 
thrown  off  its  contents,  the  necessity  for  abdominal  section  is  all  the 
more  imperative,  for  the  very  contractions  of  the  uterus  which  result 
in  the  expulsion  of  the  embryo,  result  also  in  the  extrusion  of  the 
liquid  contents  of  the  uterus  into  the  peritoneal  cavity. 

Cattle-horn  wounds  of  the  uterus  are  of  occasional  occurrence  in  the 
cattle-raising  districts  of  the  world.  A  number  of  these  cases  have 
been  reported  describing  accidents  with  revolting  details  but  attended 
with  a  singularly  slight  mortality.  These  injuries  considered  as  ab- 
dominal wounds  may  or  may  not  involve  the  uterus;  the  latter  class 
need  not  be  considered  in  this  connection.  Of  the  former  it  may  be 
said  that  they  divide  themselves  natu^rally  into  those  wounds  which 
involve  the  uterine  wall  alone,  and  those  which  involve  both  the  uterus 
and  the  child.  The  prospect  of  the  child  living  under  these  circum- 
stances depends,  naturally  enough,  upon  the  stage  of  pregnancy  and 
the  degree  of  injury  sustained  by  the  child.  Occasionally  the  rent 
in  the  uterine  wall  is  so  great  that  the  foetus  and  secundines  escape 
into  the  abdominal  cavity;  and,  even  under  these  circumstances,  a 
viable  child  has  been  known  to  survive.  Harris  {American  Journal 
of  Obstetrics,  1887)  collected  the  histories' of  nine  cases  of  this  char- 
acter, with  a  mortality  of  four  women  and  four  children.  In  an  injury 
of  this  character  the  diagnosis  declares  itself.  Whether  a  hysterectomy 
should  be  done  in  these  cases,  or  whether  the  wound  in  the  uterus  should 
be  treated  just  as  in  an  elective  Cgesarean  section,  must  be  determined  at 
the  time  by  the  conditions  presented.     As  a  rule  the  uterus  contracts 


348 


A  TEXT-BOOK  OF  GYNECOLOGY 


vigorously  after  the  receipt  of  the  injury  and  particularly  after  being 
emptied.  In  certain  of  the  recorded  cases  occurring  before  the  modern 
surgical  epoch,  closure  of  the  uterine  wound  was  effected  by  suture, 
and  even  in  cases  of  recovery  the  treatment  was  destitute  of  those 
features  which  we  should  to-day  designate  as  antiseptic.  In  some  of 
the  recorded  cases  subsequent  pregnancies  with  successful  deliveries 
have  occurred.  These  facts  should  prompt  the  operator  to  be  cautious 
before  sacrificing  a  womb  by  ablation,  even  though  it  may  be  the  seat 
of  extensive  injury. 

In  those  cases  in  which  exploratory  incision  reveals  the  fact  that 
the  perforating  wound  of  the  uterus  is  small,  delivery  may  be  effected 
by  the  Cesarean  section.  (See  Caesarean  Section.)  In  such  cases  it 
is  important  that  the  gunshot  wound  be  carefully  closed  on  the  peri- 
toneal surface  of  the  uterus. 

Foreign  bodies  in  the  uterus  are  occasionally  encountered  in  prac- 
tice. They  ma}^  consist  of  pledgets  of  cotton  or  of  gauze  left  by  acci- 
dent in  the  uterine  cavity  in  the  course  of  treatment,  the  broken  end 
of  a  uterine  electrode,  or  the  stem  of  an  intrauterine  pessary.  Schauta 
{C entralblatt  fur  Gyndl-ologie)  reported  a  case  in  which  a  hard-rubber 
pessary,  2.5  inches  in  long  diameter,  inserted  into  the  vagina,  had 
escaped  into  the  uterine  cavity  from  which  it  was  delivered  with  ex- 
treme difficulty  by  morcellement.  ISTeugebauer,  in  his  collected  series  of 
297  cases  of  pessaries  neglected  and  incarcerated  in  the  vagina  or 
escaped  into  adjacent  parts,  notes  six  in  which  a  vaginal  pessary  slipped 
into  the  uterus.  Bodies  usually  found  in  the  uterine  cavity  are  hairpins 
or  broken-off  ends  of  instruments  employed  for  the  most  part  by 
patients  themselves  in  an  effort  to  produce  abortion. 


Fig.  145.- 


-"  W.  E.  Ashton  reports  an  interesting  case  in  which  ...  a  false  passage  was  made 
from  the  internal  os  through  the  anterior  uterine  wall." — Eeed. 


W.  E.  Ashton  reports  (Medical  Bulletin)  an  interesting  case  (Fig. 
145)  in  which,  as  the  result  of  an  attempt  to  forcibly  insert  a  tupelo 
tent,  a  false  passage  was  made  from  the  internal  os  through  the  an- 
terior uterine  wall  to  a  point  above  the  utero-vesical  fold  where  the 
tip  of  the  tent  protruded  into  the  peritoneal  cavity.     Laminaria  and 


INJURIES  AND  FOREIGN  BODIES  OP  THE  UTERUS  349 

other  tents  introduced  into  the  cervical  canal  have  escaped  into  the 
uterine  cavity  proper.  Mittermaier  reports  a  case  in  which  a  loosely 
tied  silk  ligature  had  become  the  nucleus  of  an  infection  and  of  a 
foreign  body  following  an  operation  for  fibroid,  and  another  case 
in  which  the  glass  catheter  used  for  irrigating  the  uterine  cavity  had 
broken  tw  situ,  the  fragments  having  become  so  thoroughly  embedded 
that  all  attempts  to  remove  them  had  proved  futile.  The  diagnosis 
of  some  of  these  cases  in  the  absence  of  a  definite  history  can  be  made 
only  by  forcible  dilatation  of  the  cervix,  and  either  instrumental  or 
digital  exploration  of  the  uterine  cavity.  The  treatment  consists  in 
dilating  the  cervix  and,  if  possible,  removing  the  foreign  body.  This 
is  sometimes  a  matter  of  extreme  difficulty.  Thus  Schauta,  in  his 
efforts  to  remove  the  long  incarcerated  pessary  from  the  uterine  cavity, 
perforated  the  latter  repeatedly  with  a  Pacquelin  cautery  for  the  pur- 
pose of  getting  some  means  of  grasping  the  ovoid  body.  The  removal 
of  smaller  foreign  bodies  can  generally  be  effected  by  means  of  the 
curette,  the  Emmet  curette  forceps,  or  the  Lawson  Tait  colpocystotomy 
forceps.  In  some  cases,  however,  this  will  prove  unavailing;  thus,  Mit- 
termaier found  it  impossible  by  such  means  to  remove  the  fragments  of 
broken  glass  from  the  cavity  of  the  uterus,  to  accomplish  which  he  had 
to  divide  the  uterus  from  the  bladder,  draw  the  fundus  down  into  the 
vagina,  and  make  an  incision  into  the  uterine  cavity.  Having  removed 
the  glass,  he  stitched  up  the  incision,  and  returned  the  womb  to  its  nor- 
mal position.  It  is  important  to  bear  in  mind  in  cases  in  which  such  an 
operation  is  necessary  that  the  operation  shoiild  be  made  anteriorly, 
rather  than  posteriorly,  to  the  cervix.  When  a  foreign  body  results  in 
injury  and  consequent  infection,  hysterectomy  may  be  done,  as  Ashton 
did  successfully  in  the  case  to  which  reference  has  just  been  made. 


CHAPTEE  XXA^I 

INFECTIONS   OF   THE  UTERUS 

The  uterus — The  endometrium — The  myometrium — Bacteria  of  the  uterus — Infec- 
tions :  (a)  Mixed,  (6)  specific — Endometritis  and  metritis — Pathology — Causes — 
Symptoms — Diagnosis — Treatment:  (a)  Topical,  Reed's  method ;  (&)  curettage. 

The  uterus  being  a  frequent  seat  of  infections,  a  proper  compre- 
hension of  them  must  presuppose  a  knowledge  of  (a)  the  endometrium, 
(&)  the  myometrium,  (c)  the  bacteria  of  the  uterus,  and  (d)  the  recog- 
nised infections  in  their  clinical,  pathological,  and  therapeutical  aspects. 

Tlie  endometrium  consists  of  a  stroma  of  fibro-connective  and  mus- 
cular tissues  in  Avhich  are  embedded  glands  covered  by  a  single  layer  of 
columnar  ciliated  epithelium.  It  contains  lymphatics  and  nerves,  and 
the  mucous  glands  are  large  and  numerous.  The  endometrium  is  not 
supplied  with  separate  blood  vessels,  but  receives  its  nutrition  from 
the  superficial  capillaries  of  the  uterus.  The  ciliated  columnar  epithe- 
lium lines  the  entire  uterus,  also  the  uterine  glands,  and  is  continued 
through  the  Fallopian  tubes.  As  the  endometrium  approaches  the 
external  os  it  loses  its  cilia  and  becomes  blended  with  the  pavement 
epithelium  upon  the  vaginal  portion  of  the  cervix.  The  glands  are 
tubular  and  narrow,  dip  down  to  the  muscularis,  and  constitute  a  large 
portion  of  the  volume  of  the  endometrium.  These  glands  are  active 
and  maintain  a  free  secretion  upon  the  surface  of  the  membrane,  with 
a  plug  of  thick  mucus  in  the  cervical  canal.  Lymph  spaces  and  vessels 
are  abundant  throughout  the  uterus,  lying  in  the  interglandular  spaces 
around  the  bundles  of  muscular  fibres  and  in  the  serosa,  and  con- 
verging into  large  channels  which  pass  outward  in  the  broad  ligaments. 
The  cervical  endometrium  has  a  peculiar  arbor  vitse  arrangement,  is 
more  dense  than  the  corporeal,  and  is  attached  to  the  muscularis  by 
looser  tissue;  it  does  not  participate  in  menstruation.  The  normal 
secretion  of  the  endometrium  is  alkaline  in  reaction;  the  corporeal 
mucus  is  clear  and  watery,  the  cervical,  viscid.  One  important  func- 
tion of  the  cervix  is  to  close  as  by  a  sjDhincter  the  uterine  cavity;  the 
great  function  of  the  corporeal  endometrium  is  to  form  the  decidua 
and  nourish  the  embryo.  A  knowledge  of  this  function  of  the  cervix 
should  of  itself  forbid  the  much-abused  operation  of  forcible  cervical 
dilatation  in  virgins.  The  gland  crypts  of  the  cervix  readily  become 
a  culture  bed  for  germs,  which  may  long  remain  therein  in  an  attenu- 
350 


INFECTIONS   OF   THE  UTERUS  351 

ated  form,  and  under  favourable  conditions  develop  new  cultures  and 
activity. 

The  endometrium,  says  McMurtry,  is  one  of  the  most  variable  tis- 
sues of  the  body.  It  is  subject  to  alterations  that  are  physiologic, 
so  that  it  is  most  difficult  to  establish  a  normal  appearance  that  is 
typical.  This  fact  often  leads  to  a  mistaken  diagnosis  of  endometritis. 
The  endometrium  is  suffused  with  blood  during  menstruation,  under- 
goes marked  disintegration  at  that  time,  and  is  afterward  regenerated. 
During  adolescence  there  is  an  increase  in  glandular  tissue;  during 
pregnancy  this  is  even  more  marked,  and  atrophy  supervenes  after 
the  menopause.  The  blood  supply  of  the  uterus  is  altered  by  physio- 
logic and  pathologic  conditions  extraneous  to  that  organ,  such  as  nerv- 
ous states  and  wasting  disease.  These  observations  are  of  the  utmost 
importance  in  the  practical  diagnosis  and  treatment  of  uterine  dis- 
eases, and  will  convince  the'  painstaking  observer  that  the  common 
diagnosis  of  endometritis,  followed  by  aggressive  instrumentation  and 
chemical  antisepsis,  is  a  grave  error  both  in  diagnosis  and  treatment. 

The  secretion  of  the  uterine  cavity  is  alkaline;  that  of  the  vagina 
acid.  Under  normal  conditions,  the  acid  secretion  of  the  vagina  is  a 
protection  from  pathogenic  organisms  and  the  endometrium  is  always 
sterile.  Pathogenic  cocci  and  other  germs  which  might  enter  from 
adjacent  cutaneous  surfaces  perish  in  the  acid  vaginal  secretions,  which 
are  unsuited  for  their  growth.  The  reaction  of  the  vagina,  however, 
may  be  altered  by  the  presence  of  inflammatory  products,  so  that  in- 
fection may  occur  through  this  route. 

The  epithelium  on  the  crests  of  the  endometrial  folds  is  usually 
described  as  having  cilia,  which  Wyder  insists  have  a  motion  from  the  os 
internum  toward  the  fundus.  Hofmeier  {C entralhlatt  fur  Gynakologie) 
criticises  this  view.  Not  only  were  his  own  studies  conducted  upon 
fresh  uteri  removed  from  mammals,  in  which  the  conditions  ought  to  be 
the  same  as  in  the  human  female,  but  he  also  examined  organs  removed 
at  the  operating  table  and  at  once  immersed  in  warm  saline  solution.  In 
several  of  these  latter  he  demonstrated  conclusively,  by  removing  strips 
of  endometrium  and  placing  them  under  the  microscope,  that  minute 
particles  of  charcoal  were  invariably  carried  by  the  ciliary  movement 
from  the  fundus  toward  the  os  internum. 

This  observation  of  Hofmeier's  seems  at  least  to  be  in  harmony 
with  an  intelligent  design  of  Nature  by  which  obstacles  are  interposed 
to  the  easy  invasion  of  the  upper  reaches  of  the  genital  tract. 

The  endometrium,  responsive  to  the  increased  nutrition  which 
comes  from  the  premenstrual  afflux  of  the  blood  to  the  pelvis,  under- 
goes a  sort  of  periodical  hypertrophy,  preceding  each  onset  of  the 
monthly  flow.  (See  Normal  Menstruation.)  The  exuberant  epithe- 
lium undergoes  a  sort  of  desquamation.  Von  Kohlden  (Centralblatt 
fur  GynaJcologie),  who  has  studied  the  endometrium  during  and  after 
menstruation,  states  that  immediately  after  menstruation  large  gaps  are 
seen  in  llio  snpefficifil  layer  of  the  epithelium,  and  that  during  men- 


352  A  TEXT-BOOK  OF  GYNECOLOGY 

striiation  the  entire  epithelial  layer  is  east  off,  and  that  there  is  infiltra- 
tion and  hemorrhage  into  the  mucosa.  This  infiltration  may  extend 
through  two  thirds  of  the  thickness  of  the  latter.  The  blood  clots 
which  are  found  within  the  uterus  contain  desquamated  epithelium  and 
glands.  No  true  solution  of  continuity  of  the  endometrium  can  be 
established.  Von  Ivohlden  has  never  been  able  to  find  the  giant  cells 
described  by  Leopold,  or  evidence  of  dilatation  and  tortuosity  of  the 
glands.  The  reproduction  of  epithelium  begins  de  novo  within  the 
glands,  not  from  islands  of  cells  which  were  not  cast  off;  there  is  also  a 
new  formation  of  blood  vessels.  Lohlein  (Ibid.)  prefers  this  expression 
to  either  "  membranous  dysmenorrhoea "  or  "  exfoliative  endome- 
tritis," since  dysmenorrhoea  is  a  prominent  symptom  in  only  one  half 
of  the  cases,  and  most  observations  show  that  there  is  no  real  inflamma- 
tory trouble.  He  believes  that  the  membrane  bears  more  of  a  resem- 
blance to  a  product  of  conception  than  to  that  of  inflammation. 

The  myometrium,  or  the  muscularis  of  the  uterus,  consists  of  bands 
of  decussating  fibres  arranged  in  different  directions  and  in  more  or 
less  definite  concentric  layers.  Within  the  meshes  of  this  fibrillation 
are  to  be  found  numerous  nutrient  vessels,  branches  of  the  uterine  and 
ovarian  arteries,  with  their  accompanying  veins.  There  are  also  freely 
interspersed  within  the  muscularis  numerous  lymphatic  vessels,  which 
in  the  nongravid  uterus  are  minute  and  generally  closed,  but  which 
during  pregnancy  and  immediately  after  parturition  are  greatly  en- 
larged, their  orifices  communicating  directly  with  the  placental  site. 
There  are  also  numerous  nerve  filaments,  derived,  for  the  most  part, 
from  the  sacral  sympathetics. 

The  Bacteria  of  the  Uterus. — From  just  within  the  os  externum 
upward,  says  Professor  Sinclair,  the  female  genital  tract  in  health  is 
free  from  bacteria. 

Confusion  has  arisen  from  methods  of  obtaining  material  for  micro- 
scopic examination  and  cultivation  experiments.  Many  observers  have 
not  succeeded  in  getting  rid  of  the  drop  of  mucus  at  the  external  os 
which  should  be  considered  as  vaginal,  and  so  have  obtained  results 
vitiated  by  the  presence  of  vaginal  bacteria  in  the  material  examined. 

Another  trifling  question  which  has  received  too  much  attention 
is  the  limit  of  the  vagina  in  case  of  laceration  of  the  cervix.  The  dis- 
cussion is  mere  logomachy.  The  part  of  the  cervical  canal  which,  by 
reason  of  laceration,  is  exposed  to  the  vagina,  must  count  as  vagina 
from  the  point  of  view  of  bacteriological  research.  The  part  is  well 
worthy  of  examination  and  comparison  with  the  vagina  and  cervix 
proper,  because  of  the  change  in  the  reaction  of  the  secretion,  which  is 
alkaline  within  the  lacerated  portion;  the  difference  in  anatomic 
structure  of  the  part  which  is  cervical,  and  the  inability  of  its  lacerated 
muscle  to  completely  contract,  thus  leaves  the  fissure  in  a  state  of 
stagnation. 

The  external  os  uteri,  then,  thus  defined,  is  the  boundary  line  be- 
tween the  vagina  which  in  health  swarms  with  all  sorts  of  bacteria,  and 


INFECTIONS  OP   THE    UTERUS  353 

the  canal  of  the  cervix  and  body  of  the  uterus  which  in  health  is  abso- 
lutely free  from  germs.  Upon  this  point  at  least  there  is  almost  abso- 
lute unanimity  among  the  bacteriologists. 

Winter,  who  differed  so  egregiously  from  the  majority  with  regard 
to  vaginal  bacteria,  found,  on  examination  of  the  healthy  uterus  with 
apparently  healthy  secretion,  no  bacteria  in  the  cervix.  When  the 
cervical  secretion  was  purulent  he  found  bacteria  in  the  cervical  canal. 
The  material  on  which  he  worked  consisted  of  uteri  obtained  by  ex- 
tirpation. He  reached  the  following  conclusions:  (1)  The  healthy 
uterine  cavity  contains  no  micro-organisms;  (2)  the  vicinity  of  the 
OS  internum  in  half  the  cases  contains  no  bacteria;  (3)  the  cervical 
secretion  of  every  healthy  woman  contains  numerous  bacteria,  and  in 
pregnancy  the  bacteria,  especially  the  bacilli,  increase  to  a  large  extent. 
These  statements  coincide  with  those  of  many  other  German  bacteriolo- 
gists, including  Lomer  and  Bumm.  Goenner,  who  made  numerous 
observations,  found  bacteria  in  the  cervix  of  pregnant  women,  but  he 
failed  to  cultivate  any.  From  this  experience  he  draws  conclusions 
against  the  theory  of  self-infection. 

Solowieff  examined  women  suffering  from  gonorrhoea  or  from 
tuberculous  disease.  He  found  micro-organisms  in  the  cervix  in 
39  out  of  45  women  examined.  In  7  cases  he  found  streptococci  and 
staphylococci.  He  concluded  that  bacteria  are  frequently  found  in 
chronic  endometritis.  Acute  puerperal  endometritis  depends  upon 
the  presence  of  pyogenic  bacteria.  He  reached  the  conclusion  that 
the  possibility  of  self-infection  from  the  genital  canal  must  be  ad- 
mitted. 

Brandt  (Zur  Bacteriologie  der  Cavitas  Corporis  Uteri  bei  den  Endo- 
metritiden)  found,  in  22  out  of  25  cases,  bacteria  in  the  cavity  of  the 
uterus,  and  in  31  per  cent  of  cases  of  endometritis,  he  found  patho- 
genic organisms.  Similar  results  of  examinations  have  been  published 
by  many  others. 

Menge  published  the  results  of  some  work  in  1893.  He  always 
found  the  cervical  canal  free  from  germs  except  in  cases  of  gonorrhoea. 
In  these  the  gonococcus  was  always  found  in  the  cervical  canal,  and  in 
many  cases  he  obtained  the  bacterium  in  pure  cultivation.  In  preg- 
nant women  infected  with  gonorrhoea  he  always  found  the  gonococcus 
and  made  pure  cultivations  from  it.  The  secretion  of  the  cervical 
canal  was  always  alkaline. 

Stroganoff  made  observations  on  women  during  menstruation. 
After  complete  cleansing  of  the  os  externum  he  always  found  the  canal 
free  from  bacteria.  In  elderly  women,  Stroganoff  found  the  cervical 
canal  free  from  bacteria  in  50  per  cent.  When  the  uterus  was  prolapsed, 
bacteria  were  always  found  in  small  quantities  in  the  cervical  canal. 
In  pregnant  women  under  ordinary  conditions  he  always  found  the 
canal  free  from  bacteria.  StroganofF  therefore  concluded:  (1)  in 
normal  circumstances  the  cervix  contains  no  bacteria;  (2)  the  normal 
cervical  secretion  possesses  a  bactericidal  quality;  (3)  in  the  genital 
24 


354  A  TEXT-BOOK   OF   GYNECOLOGY 

canal  the  os  externum  forms  the  dividing  line  between  the  germ-con- 
taining and  the  germ-free  portions. 

Bmmn  maintained  in  1895,  that  in  chronic  endometritis  of  the 
body  and  cervix,  in  hyperplastic  conditions  resulting  from  inflamma- 
tion, as  well  as  in  the  catarrhal  form,  no  micro-organisms  can  as  a  rule 
be  demonstrated  to  exist.  The  continuance  of  the  disease  of  the 
mucosa  does  not  depend  upon  the  presence  of  micro-organisms.  In  a 
small  number  of  cases  there  may  be  found  in  the  secretion,  but  not  in 
the  tissues,  of  the  diseased  mucosa,  a  small  number  of  bacteria  includ- 
ing pyogenic  cocci.  These  must  usually  be  considered  accidental  ac- 
companiments of  the  endometritis. 

Wertheim  says  that  gonorrhoeal  infection  of  the  uterus  always 
causes  a  purulent  catarrhal  endometritis,  which,  when  it  runs  a  chronic 
course,  leads  to  hyperplastic-hypertrophic  changes  in  the  glands.  The 
inflammation  also  extends  frequently  to  the  myometrium,  and  it 
is  less  marked  in  the  cervix  than  in  the  cavum  uteri.  In  about 
half  the  cases,  the  gonococcus  was  demonstrated  in  the  secretion, 
and  pure  cultivations  were  obtained.  No  other  bacteria  were  ever 
found  when  the  gonococcus  was  present.  Wertheim  concludes  that 
the  external  os  presents  no  barrier  whatever  to  invasion  by  the  gono- 
coccus. 

Gottschalk  and  Immerwahr  examined  60  cases  and  found  bacteria, 
including  Staplit/lococcus  pyogenes,  in  the  uterine  canal  in  65  per 
cent.  The}^  concluded  that  there  was  a  secondary  invasion  of  the 
endometrium  by  the  staphylococcus  in  connection  with  a  gonorrhoeal 
infection  which  had  run  its  course  or  become  chronic. 

Menge  made  his  investigations  on  50  pregnant  women.  Of  these, 
3-i  appeared  to  be  without  any  disease  whatever;  in  16  there  was 
something  suspicious  about  the  discharge.  He  found  the  gonococcus 
in  4  cases.  In  only  3  others  were  cultivations  obtained,  and  these 
were  white  saprophytic  masses  which  softened  gelatine  very  slowly. 
He  attributes  their  presence  to  filth  from  the  vagina.  Microscopic 
examination  did  not  reveal  the  presence  of  cocci.  Bacteria  were  seen 
with  the  microscope,  but  could  not  be  cultivated.  No  bacteria  which 
we  know,  that  is  to  say,  which  can  be  cultivated  by  methods  usually 
employed  for  aerobic  and  anaerobic  germs  in  acid  or  alkaline  media, 
or  suitable  for  the  gonococcus,  could  be  discovered. 

The  conclusion  which  Menge  reaches  is,  consequently,  that  with  the 
exception  of  the  gonococcus  no  bacteria  are  found  as  a  rule  in  the 
cervix  of  pregnant  women. 

The  material  which  ]\Ienge  employed  for  his  further  work  con- 
sisted of  the  extirpated  uterus  in  50  cases  suited  for  operation.  He 
was  thus  able  to  eliminate  the  errors  arising  from  the  necessity  of 
obtaining  secretion  through  the  os  uteri.  The  diseased  conditions 
which  called  for  operation  had,  however,  led  in  many  cases  to  the  in- 
vasion of  the  cervix  by  bacteria  which  had  only  a  modified  interest  for 
the  gynecologist. 


INFECTIONS   OP   THE   UTERUS  355 

In  20  cases  Menge  found  nothing  to  suggest  pathologic  clianges 
in  the  endometrium. 

In  30  cases  there  existed  some  turbid  slimy  discharge  or  other 
changes  suggestive  of  gonorrhoeal  infection. 

Of  the  20  normal  cases  the  cultivation  material  remained  abso- 
lutely sterile  in  16.  In  the  remaining  4  cases  only  colonies  of 
saprophytes  were  discovered.  Vaginal  bacteria  were  also  found  by 
other  methods  of  cultivation,  including  an  anaerobic  streptococcus. 
In  a  large  proportion  of  the  suspicious  cases  the  gonococcus  was  found. 
All  the  rest  were  considered  to  be  vaginal  bacteria. 

It  was  found  in  the  course  of  examination  of  another  series  of  uteri 
extirpated  for  various  reasons,  that  the  tubercle  bacilkis  existed  in  the 
canal  of  the  body  and  cervix  when  tuberculous  disease  affected  the 
uterus  or  tubes.  When  necrotic  tissue  was  present,  as  in  cancer  of  the 
vaginal  portion  of  the  uterus,  innumerable  saprophytic  bacteria  were 
found  to  flourish. 

Among  the  causes  of  the  immunity  from  bacterial  invasion  of  the 
cervical  canal  Professor  Sinclair  suggests: 

1.  The  difference  in  the  reaction  of  the  secretion,  which  keeps 
away  from  the  cervix  the  facultative  aerobes  and  pathogenic  organisms 
which  sometimes  gain  a  footing  in  the  vagina. 

2.  The  sudden  change  in  the  calibre  of  the  canal. 

3.  Increase  of  the  muscular  power  of  the  walls  of  the  canal. 

4.  The  downward  stream  of  the  secretion,  which  may  add  another 
mechanical  influence. 

5.  Some  germicidal  quality  in  the  secretion — that  is,  in  the  leuco- 
cytes and  in  the  fluid. 

6.  The  presence  of  the  gonococcus  when  it  has  obtained  access  to 
the  cervix. 

In  reference  to  this  last  jooint  there  can  be  no  doubt  that  the  os 
externum  and  all  the  influences  at  work  in  the  cervix  present  no 
obstacle  to  the  advance  of  the  gonococcus,  and  there  is  reason  to  believe 
that  the  presence  of  the  gonococcus  has  some  deterrent  influence  on  the 
development  of  other  bacteria. 

From  what  has  now  been  said  about  the  cervical  canal,  and  a  fortiori 
about  the  canal  of  the  uterus  as  a  whole,  certain  practical  conclusions 
may  be  indicated  without  unpardonable  irrelevancy.  It  must  be  obvi- 
ous that  the  cervical  canal  of  the  pregnant  or  parturient  woman  does 
not  require  disinfecting,  and  that  any  proceedings  with  that  object  are, 
to  say  the  least,  unnecessary. 

When  the  cervical  canal  is  found  to  be  the  source  of  gonorrhoeal  dis- 
charge in  the  woman  in  labour,  disinfection  is  not  possible.  From  the 
bacteriological  standpoint,  attempts  to  disinfect  the  cervix  before  or 
during  labour  are  inadvisable. 

In  women  suffering  from  fibromyoma  of  the  uterus,  it  used  to  be 
the  custom  fluring  operation  to  dissect  out  or  destroy  by  cautery  the 
mucosa  of  tlie  cervix,  for  fear  of  the  stump  in  the  intraperitoneal 


356  ^         ^  TEXT-BOOK  OF   GYNECOLOGY 

operation  becoming  infected.  The  fear  of  infection  at  this  point  was 
also  used  as  an  arg'unient  in  favour  of  pan-hysterectomy.  It  is  obvi- 
ous from  the  teaching  of  bacteriology  that  all  these  operative  details  are 
unnecessary,  and  the  argument  as  to  pan-hysterectomy  is  all  on  the 
other  side. 

Some  interesting  reflections  arise  in  connection  with  this  subject, 
in  relation  to  the  vicissitudes  in  the  history  of  lamina  da  tents.  In 
Sinclair's  opinion,  tents  are  still  the  unrivalled  means  of  dilating  the 
nonpregnant  uterus.  The  tents  can  be  disinfected,  the  houchon 
muqueux  can  be  removed  from  the  os  externum,  and  then  the  canal 
is  germ-free.  Whence  arise  the  exceptional  cases  of  acute  bacterial 
infection  following  the  use  of  tents?  Probably  from  some  occult 
arrested  condition  of  the  gonococcus  or  from  the  life  energies  of  bac- 
teria not  yet  discovered. 

We  are  now  in  a  position  to  appreciate  the  dictum:  The  asepsis- 
of  the  healthy  genital  canal  in  a  pregnant  woman  begins  at  the  introitus 
vagince,  and  the  germ-free  portion  begins  at  the  os  externum.  In  the  non- 
pregnant woman  the  cervical  canal  is  also  germ-free. 

It  is  hardly  necessary  to  consider  the  cavity  of  the  uterus  as  a  dis- 
tinct part  of  the  genital  tract — a  conclusion  in  which  Professor  Sin- 
clair is  in  accord  with  other  advanced  investigators.  The  result  of 
such  consideration  is  to  emphasize  the  fact  of  immunity  from  organ- 
isms. All  the  work  of  bacteriologists  who  have  obtained  material  by 
the  curette  or  spoon,  as  applied  to  the  cavity,  may  be  set  aside  as- 
vitiated  by  the  mixing  of  material  from  the  vagina.  The  most  trust- 
worthy results  have  been  obtained  by  examination  of  the  uterus  im- 
mediately after  extirpation.  Wertheim,  whose  work  was  pursued 
chiefly  with  the  object  of  investigating  the  pathology  of  the  sexual 
organs  resulting  from  gonorrhoeal  infection,  concluded  that  the  cavity 
of  the  uterus  contained  either  the  gonococcus  or  no  bacteria  of  any  kind. 

Menge  worked  on  the  vast  material  of  118  uteri  obtained  by  ex- 
tirpation, and  the  uterine  canal  in  every  case  was  immediately  ex- 
amined for  bacteria  both  by  microscopic  examination  and  by  cul- 
tivation experiment.  He  devoted  a  good  deal  of  time  and  trouble 
to  the  investigation  of  pyometra,  which  is  almost  always  a  result  of 
bacterial  invasion  from  malignant  disease  of  the  cervix,  a  work  of 
supererogation  as  far  as  our  subject  is  concerned.  He  might  as  well 
have  given  us  the  results  of  researches  on  the  bacteria  which  infest 
the  cancerous  area  itself  and  produce  the  foul  smell  of  the  discharge 
and  other  phenomena. 

On  the  ground  of  bacteriological  researches  Menge  concluded  that, 
neither  in  the  secretion,  nor  in  the  tissues  of  the  mucosa  of  the  normal 
cavity  of  the  body  of  the  uterus,  did  bacteria  exist  which  could  be  culti- 
vated in  our  usual  media;  and  that,  neither  in  the  secretion,  nor  in  the 
tissues  of  the  mucosa  of  such  uteri  as  showed  in  the  corporeal  mucosa, 
the  usual  anatomic  changes  marking  the  individual  forms  of  chronic 
endometritis  with  small-cell  infiltration,  did  bacteria  exist  which  could 


INFECTIONS  OF  THE   UTERUS  357 

be  cultivated  according  to  any  of  our  known  methods.  An  exception 
must  always  be  made  as  to  the  gonococcus  and  the  tubercle  bacillus. 

With  regard  to  the  tubercle  bacillus  it  is  a  curious  fact,  to  which 
Professor  Sinclair  calls  attention,  that  though  tuberculous  disease 
exists  either  primarily  or,  more  frequently,  secondarily,  in  the  cavity 
of  the  body,  it  seldom  extends  downward  beyond  the  os  internum, 
while  in  most  cases  of  malignant  disease  of  the  cervix,  the  process 
comparatively  seldom  extends  upward  beyond  the  os  internum. 

Individual  cases  of  chronic  endometritis  stand  probably  in  some 
causal  relationship  with  the  bacterial  producers  of  puerperal  infection 
and  intoxication.  The  chronic  endometritis  of  the  nonpregnant 
woman  is,  however,  not  perpetuated  by  these  micro-organisms. 

The  cavity  of  the  body  of  the  uterus  can  be  invaded  by  bacteria, 
or  can  for  a  considerable  time  harbour  bacteria  when  it  is  injured, 
and  bacteria  are  conveyed  to  it  by  direct  inoculation,  or  when  the 
defensive  power  of  the  cervix  is  inhibited  by  dilatation  and  the  unfold- 
ing of  its  rug^e,  either  by  new  growths  or  by  products  of  conception. 

Infections  of  the  uterus  may  be  appropriately  classified  as  (a) 
mixed,  and  (b)  specific.  The  mixed  infections  are  those  in  which  patho- 
genic bacteria  of  various  classes  are  carried  into  the  uterus  and  estab- 
lish inflammatory  changes  in  the  endometrium,  or  possibly  subse- 
quently in  the  myometrium,  or  even  in  the  perimetric  structures.  As 
will  be  seen  when  the  pathology  of  these  infections  is  considered,  they 
are  but  rarely  limited,  at  least  in  their  sequent  changes,  to  the  lining 
membrane  of  the  uterus;  but  through  the  utricular  glands  or  the  open 
lymph  spaces  the  infection  extends  into  the  underlying  muscular  struc- 
ture; or,  in  the  absence  of  absolute  invasion  by  morbific  micro-organ- 
isms, the  secondary  inflammatory  phenomena,  in  view  of  the  non- 
existence of  a  submucous  connective  tissue  within  the  uterus,  are 
manifested  directly  in  the  myometrium.  Specific  infections  probably 
never  exist  as  such  if  the  term  is  construed  to  mean  an  infection  due 
exclusively  to  a  particular  micro-organism;  there  are,  however,  cases 
in  which  a  special  bacterial  organism — e.  g.,  the  Streptococcus  pyogenes, 
the  gonococcus,  the  Bacillus  tuberculosis — exercise  a  predominating 
influence  in  producing  pathologic  changes,  some  of  which  are  charac- 
teristic of  the  respective  specific  infection.  It  is  probably  not  a  demon- 
strable fact  that  any  well-developed  infection,  however  closely  it  may 
approximate  the  specific  standard,  ever  exists  except  as  a  mixed  infec- 
tion; yet,  as  in  the  cases  of  puerperal  fever,  gonorrhoea,  tuberculosis,  and 
especially  in  parasitic  invasions — e.  g.,  the  echinococcus — the  organism 
which  exercises  the  controlling  influence  is  so  distinct,  its  characteris- 
tics are  so  well  understood,  its  clinical  manifestations  are  so  definite, 
that  the  fondition  should  be  discussed  as  one  of  specific  infection. 

Endometritis  not  depending  upon  specific  micro-organisms  for  its 
causation,  is  the  first  and  most  frequent  manifestation  of  ordinary 
mixed  infections  of  the  uterus.  This  terra,  etymologically,  means  an 
inflammation  of  the  lining  membrane  of  the  uterus.     There  is  serious 


358         '    A  TEXT-BOOK  OF  GYNECOLOGY 

question  whether  this  condition  ever  exists  as  a  distinct  clinical  and 
pathologic  entity — although  Welch  has  stated  that  he  has  seen  cases 
of  genuine  inflammation  which  can  be  called  nothing  hut  endometritis 
(American  Obstetrical  and  Gynecological  Journal).  The  connection 
between  the  endometrium  and  the  myometrimn  being  intimate,  there 
being  no  intervening  cellular  structure  and  a  common  circulatory  and 
lymphatic  arrangement,  it  follows  that  inflammatory  processes  origi- 
nating in  the  endometrium  are  exceedingly  prone  to  penetrate  the 
muscularis.  In  those  cases  in  which  the  inflammatory  process  is  limited 
to  the  endometrium,  such  limitation  probably  exists  simply  in  con- 
sequence of  either  the  relatively  slight  virulence  of  the  infectious 
elements,  or  the  relatively  short  duration  of  the  disease,  or,  a  third 
possibility,  because  resolution  has  taken  place  in  the  deejjer  struc- 
tures. As  a  matter  of  fact,  inflammatory  exudations  are  generally 
observed  in  at  least  the  superficial  strige  of  the  muscularis  in  practically 
all  demonstrated  cases  of  endometritis;  and  it  is  also  true  that  in 
many  cases  of  infections  which  must  of  necessity  commence  in  the 
endometrium,  the  most  essential  pathologic  changes  are  manifested 
in  the  parenchyma.  It  is  to  be  concluded,  therefore,  that,  patholog- 
ically speaking,  infection  of  the  endometrium  implies  an  inflammatory 
disturbance,  not  alone  of  the  mucosa,  but  also  of  the  muscularis,  and 
should,  therefore,  be  designated  as  metritis. 

Backer  denies  that  inflammation  of  the  uterine  mucous  membrane 
exists  as  a  separate  condition.  He  believes  it  to  be  always  associated 
with  inflammation  of  the  body  of  the  uterus,  and  classifies  it  accord- 
ing to  the  French  plan  among  the  metriticles.  He  divides  metritis 
into  the  following  groups: 

I.  Uncomplicated  infectious  form:  {a)  catarrhal  metritis;  (&)  gonor- 
rhoeal  metritis. 

II.  Complicated  forms:  (a)  metritis  post  abortium;  (&)  metritis  ex- 
foliativus;   (c)  metritis  atrophicans. 

The  diagnosis  between  the  forms  of  Group  II  is  easy,  but  the 
catarrhal  is  hard  to  distinguish  from  the  gonorrhoeal  metritis.  The  pres- 
ence of  gonococei  is  pathognomonic;  in  their  absence  the  clinical  his- 
tory must  furnish  the  decisive  details.  The  ordinary  "  catarrhal " 
metritis,  such  as  results  from  excessive  venery,  onanism,  and  displace- 
ments of  the  uterus,  is  not  an  inflammation  but  simply  a  hyperasmia 
which  disappears  when  the  cause  is  removed. 

The  position  assumed  by  Backer  is  that  entertained  by  Pozzi  and 
numerous  other  modern  writers  and  pathologists;  and  it  is  the  view 
upon  which  the  discussion  of  infection  will  be  based  in  this  work. 
The  terms  endometritis  and  metritis  will  both  be  employed;  the  former, 
in  particular,  because  it  designates  inflammation  of  the  lining  mem- 
brane of  the  uterus,  to  whatever  extent  the  myometrium  also  may  be 
involved.  It  is  convenient  for  the  purpose  of  designating  inflammatory 
processes  of  the  uterus  since  the  most  important  phenomena  of  them 
are  manifested  upon  its  internal  surface. 


INFECTIONS  OF   THE    UTERUS 


559 


The  ground  upon  which  endometritis  should  he  considered  as  a 
mixed  infection  is  firmly  estahlished.  Brandt  found  pathogenic 
organisms  in  31  per  cent  of  his  cases  of  endometritis.  Other  ob- 
servers have  found  them  in  larger  proportions  of  cases.  The  fact 
that  Brandt's  cases  embraced  both  acute  and  chronic  endometritis 
favours  the  doctrine  of  a  bacterial  causation  in  a  much  larger  per- 
centage of  the  acute  cases  than  was  demonstrable;  for,  as  is  well 
known,  bacteria  within  the  uterus  are  relatively  self-limiting,  while 
the  pathologic  changes  which  they  induce  may  continue.  It  follows 
from  this,  that  in  many  cases  of  so-called  chronic  endometritis  in 
which  no  bacteria  can  be  demonstrated,  the  organisms  have  disap- 
peared by  process  of  self-limitation. 

The  pathologic  changes  that  are  induced  by  an  acute  mixed  infec- 
tion are  simply  those  characteristic  of  an  acute  inflammation  in  the 
mucous  membrane.     There  is  an  immediate  turgescence  of  the  sub- 


FiG.  146. — "  The  stage  of  inflammatory  exudation  is  speedily  reached." — Reed. 


epithelial  cay)il]aries,  with  a  consequent  overstimulation  of  glandular 
activity.  The  influence  of  the  micro-organisms  or  of  their  toxines 
is  such  as  to  destroy,  in  some  cases,  the  superficial  epithelium  in  the 
more  exposed  area,  while  the  germs  themselves  penetrate  deeply  into 
the  mucous  folds  and  the  utricular  follicles.  The  stage  of  inflamma- 
tory exudation  is  speedily  reached  (Fig.  14G),  and  differs  fi'oni  the  same 


360  '  A  TEXT-BOOK  OF   GYNECOLOGY 

stage  of  inflammation  in  other  tissues  in  the  fact  that  there  is  no 
nnderlj'ing  submucous  connective  tissue  to  become  the  receptacle  of 
the  transuded  liquor  sanguinis  and  the  migrated  cellular  elements 
of  hematogenous  origin.  The  exudation  on  the  other  hand  takes 
place^  at  least,  to  an  important  degree,  directly  among  the  fibrillae 
of  the  myometrium.  In  exceptional  cases,  however,  the  exudation 
takes  place  more  distinctly  between  the  mucous  membrane  and  the  mus- 
cularis,  with  the  result  that  the  former  is  sometimes  separated,  in 
part  at  least,  from  the  latter.  It  is  this  condition  that  occasions  severe 
dysmenorrhcea.  Winter  asserts  that  it  is  the  origin  of  some  cases  of 
dysmenorrhoea  of  the  membranous  variety.  The  sero-albuminous  de- 
posit gives  to  stained  sections  an  appearance  more  transparent  than 
is  observed  in  the  normal  mucous  membrane.  The  changes  incident 
to  resolution  now  manifest  themselves  in  the  disappearance  of  the  liquid 
elements  of  the  exudate,  and  in  the  migration  of  the  leucocytes  toward 
the  surface  or  into  the  minute  lymphatics,  until  presently  both  the  cel- 
lular and  the  noncellular  elements  of  the  exudation  have  disappeared. 
In  many  cases,  however,  in  consequence  of  the  peculiar  structure  of 
the  endometrium,  there  exist  within  the  deep  follicles  bacterial  elements, 
which,  modified  in  their  virulence,  perpetuate  in  a  lesser  degree 
the  original  inflammatory  changes.  The  persistence  of  this  irritation 
is  sufficient,  not  only  to  prevent  the  resorption  of  the  exuded  elements, 
but  to  effect  their  continued  deposition  and  organization.  The  result 
is  a  distinct  hyperplasia,  characterized  by  an  increased  thickness  of 
the  mucous  membrane.  A  section  of  the  mucosa  reveals  that  it  is 
of  increased  depth,  while  its  cellular  elements  are  not  only  relatively 
but  absolutely  increased  in  number.  The  leucocytes  are  found  in 
some  cases  in  large  interstitial  deposits,  while  the  blood  vessels  them- 
selves show  but  slight  thickening  of  their  walls.  As  a  result  of  these 
interstitial  deposits  increased  pressure  is  exercised  upon  the  glands 
which  now  seem  smaller  and  relatively  fewer  in  number.  In  this  stage, 
bacterial  elements  have  generally  disappeared  from  the  secretion,  the 
withdrawal  of  their  influence  resulting  in  the  more  or  less  speedy  super- 
vention of  the  next  stage  of  the  process;  this  is  characterized  by 
an  absorption,  to  a  certain  degree,  of  the  remaining  free  elements 
of  exudation,  but  without  any  material  diminution  in  the  number 
or  size  of  the  hyperplastic  products.  These,  on  the  contrary,  con- 
tinue to  exercise  pressure  upon  the  already  compressed  glands  which 
now  undergo  atrophy;  or,  as  may  happen,  an  efferent  duct  may  be- 
come occluded  and  the  underlying  follicle  thus  become  converted 
into  a  retention  cyst.  Some  of  the  glands,  instead  of  being  at  right 
angles  to  the  mucous  surface,  as  under  normal  conditions,  become 
oblique,  and  the  stroma  is  characterized  by  increased  density,  and,  on 
section,  shows  cells  that  have  become  elongated  and  arranged  in  bun- 
dles and  fasciculi.  The  changes  that  are  now  presented  are  very  much 
like  those  observable  in  the  senile  uterus.  In  these  cases  there  is 
generally  diffuse  sclerosis  of  the  muscularis. 


INFECTIONS   OF  THE  UTERUS  361 

The  most  ordinary,  and  more  or  less  persistent,  change  following 
an  acute  infection  of  the  uterus  is  that  of  glandular  hyperlrophic  endo- 
metritis. In  this  form  the  cellular  changes  are  restricted  chiefly  to 
the  epithelium,  the  cells  of  which  undergo,  not  only  hypertrophic,  but 
hyperplastic  changes.  The  result  is  essentially  one  of  increased 
glandular  development,  with  corresponding  increase  of  functional  capa- 
city. The  glands  seem  to  be  increased  in  size  and  number  and  to 
be  studded  more  closely  together  than  in  normal  conditions.  The 
exuberance  of  epithelial  cell  growth  results  in  an  apparent  thickening 
of  the  endometrium,  which  now  appears  to  be  arranged  in  slight  folds, 
on  the  apices  of  which,  more  distinctly  than  elsewhere,  the  cell  de- 
velopment seems  to  be  luxuriant.  On  section,  the  mucous  glands, 
instead  of  being  straight  tubules  projecting  downward  into  the  stroma, 
are  found  to  be  tortuous,  or,  in  other  cases  to  show  simple  devia- 
tion in  axis.  On  cross  section  their  calibres  are  found  to  be  widened, 
their  lumen  being  largely  occupied  by  the  exuberant  cell  growth.  In 
this  class  of  cases  the  lumen  of  the  mucous  gland  often  becomes  so 
distended  with  newly  formed  epithelial  elements  that  the  latter  project 
from  the  ostium  and  appear  upon  the  surface  with  a  sort  of  granu- 
lation. In  the  more  distinctly  hyperplastic  varieties,  there  seems  to 
be  not  only  an  increase  in  the  number  of  the  tissue  elements,  but  a 
multiplication  of  the  glands  themselves.  These  glands  increase  in  size 
and  number,  and  sometimes  show  a  marked  increase  in  the  interglandu- 
lar  stroma.  The  exuberant  cell  growth  in  these  cases  results  in  a 
thickening  of  the  mucous  membrane,  the  surface  of  which  presents  a 
fungous  appearance.  It  is  for  this  reason  that  the  condition  is  some- 
times called  fungous  endometritis.  As  the  epithelial  cells  develop 
from  the  matrix  there  is  demonstrable  a  certain  proliferation  of  the 
sanguiniferous  capillaries  to  give  them  support.  The  cell  growth  is, 
however,  so  active  that  it  gets  beyond  the  influence  of  the  nutrient 
supply  and  undergoes  fatty  degeneration.  When  this  occurs,  the  ter- 
minal filaments  of  the  newly  proliferated  vessels  are  exposed,  and 
hemorrhage  results. 

It  is  sometimes  important  to  distinguish  areas  of  glandular  hyper- 
trophy occurring  upon  a  limited  area  of  everted  cervical  membrane, 
from  syphilitic  infection.  In  the  first  place  the  primary  syphilitic  sore 
of  the  portio  vaginalis  is  rare,  and  when  it  occurs  it  is  manifested 
by  a  distinct  erosion,  ulcerative,  with  sharply  defined  borders.  It 
is  in  nearly  every  case  associated  with  induration  of  (1)  the  intra- 
pelvic  l}Tnphatics,  and  later  (2)  those  in  the  inguinal  regions.  Chan- 
croids are  liable  to  be  overlooked,  as  they  are  generally  painless  and, 
aside  from  an  ofi'ensive  discharge,  produce  no  symptoms. 

The  causes  of  endometritis  may  be  summarized  in  the  general  word 
infection.  There  are,  however,  numerous  conditions  which  seem  to 
contribute  to  this  infection.  As  has  been  shown  by  Sinclair,  the 
uterine  cavity  from  the  os  externum  to  the  fundus  is  normally  free  from 
bacteria.     A^Tien  infection  occurs  above  the  external  os  i1  must  be  as 


362  A  TEXT-BOOK  OF  GYNECOLOGY 

the  result  of  the  carriage  thither  of  the  infectious  element.  The  use 
of  instruments  to  produce  abortion^  and  the  employment  of  the  uterine 
sound  for  more  legitimate  purposes,  may  be  held  responsible  for  a  large 
number  of  cases.  The  use  of  an  unclean  speculum  is  a  reasonable 
explanation  of  the  infection  of  the  upper  portion  of  the  vagina,  whence 
the  infection  may  extend  by  progressive  invasion  of  the  mucous  sur- 
faces to  the  endometrium.  Pessaries,  for  the  most  part  unclean  and 
stinking  things,  are  to  be  looked  upon  with  more  than  suspicion.  The 
use  of  an  unclean  syringe  nozzle  is  dangerous.  There  are  certain  phys- 
ical conditions  of  the  uterus  that  are  undoubtedly  predisposing  causes 
of  infection.  Laceration  of  the  cervix,  b}^  exposing  a  portion  of  the 
endocervium  to  the  infectious  elements  that  abound  in  the  vagina,  may 
pave  the  way  for  a  more  general  involvement.  Schultze  has  called 
attention  to  the  influence  of  a  chronic  dilatation  of  the  cervix  in  favour- 
ing the  introduction  of  morbific  agencies  into  the  uterine  cavity.  Pro- 
lapsus of  the  uterus,  when  complete,  is  generally  associated  with  more 
or  less  infection  of  the  endometrium.  Uterine  displacements  in  gen- 
eral may  be  looked  upon  as  contributory  influences  in  producing  the 
pathologic  states  which  are  found  in  patients  with  associated  demon- 
strable infection. 

Neoplasms  of  the  uterus,  particularly  when  they  have  become  the 
seat  of  retrogressive  changes,  are  a  source  of  infection.  Abel  and  Lan- 
don,  after  making  numerous  careful  microscopic  studies,  arrived  at 
the  conclusion  that  in  cases  of  cancer  of  the  cervix  the  corporeal  endo- 
metrium undergoes  marked  changes — especially  of  an  inflammatory 
character. 

Acute  infectious  diseases  have  been  looked  upon  as  causes  of  endo- 
metritis. Massin  of  St.  Petersburg  {Arcliiv  fiir  Gyndl-ologie)  made  an 
efl^ort  to  settle  this  question  by  conducting  a  series  of  experiments  upon 
eighteen  cases.  Of  these,  twelve  were  cases  of  relapsing  fever,  two  of 
pneumonia,  two  of  enteric  fever,  one  of  dysentery,  and  one  case  of  acute 
general  peritonitis  of  unkno-ooi  causation.  The  uterus,  with  the  adnexa, 
was  removed  at  the  autopsy  and  placed  in  Miiller's  fluid,  and  allowed  to 
remain  therein  from  a  month  to  six  weeks.  Sections  were  made  from 
different  portions  of  the  uterine  walls,  including  the  os  internum  and 
cervix.  They  were  first  kept  in  alcohol  (70  per  cent),  then  placed 
in  absolute  alcohol  for  one  week,  and  then  in  photoxylin  solution.  The 
sections  were  stained  with  borocarmine,  picrocarmine,  eosin,  and 
methylene  blue.  From  an  examination  of  these  specimens  the  follow- 
ing conclusions  were  arrived  at:  "  The  mucosa  is  afl^ected  in  all  of  these 
acute  infectious  diseases,  as  are  the  glands,  the  vessels,  and  the  uterine 
muscular  fibres.  Firstly,  they  are  all  markedly  injected.  The  injec- 
tion may  be  marked  in  one  portion  of  the  mucous  membrane,  or,  as  was 
usually  the  case,  may  afi^ect  the  entire  mucous  membrane.  The  in- 
creased size  of  the  vessels  was  especially  noted  in  the  small  veins  and 
capillaries.  The  arteries  were  empty,  and  in  only  a  few  cases  did  they 
contain  formed  blood  elements.     In  many  cases  the  dilatation  was  so 


INFECTIONS  OF  THE   UTERUS  363 

great  as  to  cause  a  rupture  of  the  vessels,  and  consequently  hemorrhages 
into  the  mucous  membrane  and  between  the  muscular  layers.  These 
ecchymoses  occurred  in  cases  irrespective  of  the  age  of  the  patients. 
The  most  marked  cases  of  dilatation  and  rupture  were  those  in  which 
the  disease  had  been  continuous,  as  in  the  cases  of  pneumonia  and 
enteric  fever,  whereas  in  the  cases  of  relapsing  fever  hemorrhages  were 
only  found  in  half  of  the  cases.  Next,  in  reference  to  the  glands.  The 
epithelium  lining  these  was  always  swollen  and  cloudy,  having  rounded 
edges;  the  cells  were  coloured  with  difficulty.  The  epithelial  cells 
secreted  more  mucus  than  normally.  In  some  cases  the  glands  were 
markedly  enlarged.  In  many  cases  the  epithelium  was  detached  from 
the  glandular  tissue  and  lay  in  irregular  masses  in  the  glandular  cavi- 
ties. The  membrana  propria  of  the  glands  and  the  surrounding  layer 
of  spindle-shaped  cells  were  well  marked  in  nearly  all  of  the  cases. 
We  frequently  observed  new-formed  granular  elements,  which  were 
arranged  around  the  glands  in  the  form  of  a  belt.  The  muscular  layer 
of  the  uterus  did  not  seem  to  be  much  affected  by  the  disease.  As 
stated  above,  the  vessels  in  the  muscular  layer  were  injected.  The 
changes  which  we  observed  represent  a  parenchymatous  and  interstitial 
inflammation  of  the  mucous  membrane  and  an  interstitial  inflammation 
of  the  muscular  layer.  Furthermore,  in  all  of  the  cases  a  condition 
was  observed  which  can  be  termed  a  hemorrhagic  endometritis.  AVe 
naturally  conclude,  after  having  made  these  experiments,  that  the 
endometritis  undergoes  three  processes:  1.  Increased  amount  of  blood 
to  the  uterus,  venous  stasis,  and  inflammation  of  the  vessels;  2.  Granu- 
lar inflammation;  3.  Diffuse  spreading  of  this  inflammation.  In  our 
experiments  we  were  unable  to  ascertain  whether  micro-organisms  were 
present  or  not.  We  must,  therefore,  consider  acute  infectious  diseases 
as  important  factors  in  the  causation  of  uterine  diseases,  so  that  when 
we  consider  the  etiology  of  acute  and  chronic  endometritis  we  must 
always  think  of  the  possibility  of  the  affection  being  the  result  of  an 
acute  infectious  disease." 

The  symptoms  of  endometritis  vary  somewhat  according  to  the 
pathologic  changes  upon  which  they  depend.  In  the  simple  infec- 
tions of  the  endometrium  involving  only  the  superficial  epithelium 
and  the  mucous  follicles,  there  occurs  a  discharge  ordinarily  designated 
as  uterine  leucorrhoea.  This  discharge  is  generally  clear  and  viscid 
and  is  occasionally  stained  with  blood.  It  is  sometimes  of  a  distinctly 
muco-purulent  character.  Schultze,  recognising  the  fact  that  purulent 
elements  may  be  so  slight  in  the  uterine  discharge  as  to  escape  detec- 
tion, advises  the  use  of  a  glycerine  tampon  for  diagnostic  purposes.  The 
tampon  should  be  removed  by  the  surgeon,  who  should  carefully  inspect 
it  and  thereby  ascertain  with  accuracy  the  presence  or  absence  of  puru- 
lent elements.  In  cases  of  long  standing,  frequent  hemorrhages,  oc- 
curring either  in  connection  with  menstruation  or  during  the  inter- 
menstrual period,  are  to  be  construed  as  evidences  of  fungous  degen- 
eration of  the  endometrium.     There  may  or  may  not  be  dysmenorrhoea. 


364  A  TEXT-BOOK  OF   GYNECOLOGY 

and  the  uterus  may  or  may  not  be  enlarged.  The  cervix  in  the  major- 
ity of  cases  is,  however,  the  seat  of  more  or  less  engorgement  or  infiltra- 
tion, or  may  even  be  oedematous.  In  some  cases  the  uterus  may  be 
painful,  a  condition  which  Sneguireff  of  Moscow  designates  as  endome- 
tritis dolorosa.  Sensibility  of  this  character  is  generally  more  marked 
at  the  fundus. 

The  diagnosis  depends  not  only  upon  the  symptomatology,  but 
especially  upon  the  demonstration  by  microscopic  and  bacteriological 
examination  of  bacterial  elements  in  the  uterine  secretion.  If  the 
endometrium  is  everted  at  the  cervix  and  presents  a  granular  appear- 
ance the  case  is  one  of  glandular  hypertro]3hy.  If  hemorrhages  are 
present  there  exists  a  strong  suspicion  of  endometritis  fungosa.  It 
should  be  remembered,  however,  that  hemorrhage  is  a  conspicious 
symptom  of  various  malignant  processes,  not  only  of  the  cervix  but  of 
the  corpus  uteri.  (See  Symptoms  of  Malignant  Neoplasms  of  the 
Uterus).  In  view  of  these  facts  and  under  these  circumstances  it  is 
imi^erative  that  the  uterine  cavity  be  explored.  The  cervix  should  be 
dilated.  This  is  done  preferably  by  some  of  the  mechanical  dilators, 
such  as  Palmer's  convenient  device;  or,  as  preferred  by  Sinclair,  a 
carefully  sterilized  laminaria  tent  may  be  then  employed.  The  chief 
objection  to  the  latter  is  the  time  and  discomfort  involved  in  its  use. 
Dilatation  should  be  carried  to  a  degree  that  will  admit  of  the  easy 
introduction  of  a  curette  or  of  a  curette  forceps.  Either  one  or  the 
other  of  these  instruments  should  then  be  inserted  and  by  gentle 
scraping  some  of  the  intrauterine  tissue  should  be  removed.  This 
should  be  carefully  preserved  and  examined  microscopically.  Gessner 
{Zeitschrift  fiir  GehurtsMUfe  u.  Gtjnakologie)  in  a  careful  discussion  of 
the  techniqiTC  of  exploratory  curettage  states  that  anaesthesia  is  useful 
although  not  indispensable.  The  dilatation  is  to  be  carried  to  a  degree 
that  will  admit  of  the  introduction  not  only  of  the  curette,  but  subse- 
quently of  an  irrigation  catheter.  A  sharp  curette  is  to  be  employed 
and  the  whole  interior  of  the  uterus  must  be  carefully  scraped  and  every 
fragment  so  removed  must  be  examined  under  the  microscope.  Unless 
this  precaution  is  taken,  evidences  of  malignancy  which  may  be  derived 
from  a  very  limited  area  may  escape  detection.  Sanger  recommends 
that  the  uterine  canal  be  dilated  by  means  of  laminaria  tents  until  not 
only  a  curette,  but  also  the  finger,  can  be  introduced  into  the  uterine 
cavity.  He  states  that  in  those  affections  of  the  corpus  in  which  malig- 
nancy is  always  to  be  suspected,  the  use  of  the  curette  is  superior  to 
simple  palpation,  but  palpation  with  curettage  and  microscopic  exam- 
inations of  any  dehris  that  may  be  removed  will  give  more  information 
than  the  two  latter  only.  While  Sanger  insists  upon  this  technique  in 
cases  of  abortion  and  of  myomata  of  the  corpus  uteri,  he  recognises  in 
digitation  a  valuable  diagnostic  expedient  in  certain  enlargements  of 
the  uterus  associated  with  involvement  of  the  endometrium.  Gessner, 
in  speaking  of  the  diagnostic  value  of  exploratory  curettage,  states 
that  in  the  FrauenMinik  of  the  University  of  Berlin,  a  diagnosis  of 


INFECTIONS  OF  THE  UTERUS  365 

malignant  disease  of  the  corpus  uteri  had  been  made  and  the  organ 
had  been  extirpated  in  fifty-eight  cases  during  a  few  years.  In  eleven, 
carcinoma  could  be  distinctly  felt  through  the  dilated  cervix;  in  three 
others  in  which  the  finger  could  reach  the  new  growth  the  disease  was 
found  to  be  sarcoma.  In  forty-one  cases,  however,  the  diagnosis  was 
made,  not  by  digitation,  but  by  exploratory  curettage.  He  looks  upon 
the  latter  as  the  more  valuable  expedient.  When  the  scrapings  are 
examined  the  diagnosis  will  be  established  by  their  resemblance  to  the 
histopathologic  appearances  already  described. 

The  treatment  of  endometritis  must  depend  somewhat  upon  the 
particular  pathologic  condition  that  may  be  presented  at  the  time.  In 
the  simple  catarrhal  forms,  in  which  the  most  annoying  symptom  is  a 
persistent  leucorrhcea,  reliance  is  often  placed  upon  topical  remedies. 
As  has  been  shown  in  the  discussion  of  the  pathology  of  this  condition, 
there  exist  such  organic  changes  that  any  results  that  may  follow  the 
use  of  local  medication  must  be  at  best  slow  and  uncertain.  It  may  be 
stated  as  a  rule  that  intrauterine  medication  for  catarrhal  conditions 
is  unsatisfactory.  There  are  patients,  however,  who  prefer  to  be 
treated  locally  for  a  long  time  rather  than  to  submit  for  a  few  days  to 
anything  suggestive  of  surgical  intervention.  In  these  cases  treatment 
should  consist  in  the  use  of  bactericidal  agents.  These  should  be  so 
applied  that  the  entire  mucous  surface  should  be  subjected  to  their 
influence;  for,  if  a  portion  of  the  mucous  surface  remains  untreated, 
and  consequently  infected,  it  becomes  the  focus  for  the  reinfection  of 
the  entire  structure.  Another  principle  of  equal  importance  is,  that 
an  intrauterine  application  of  a  bactericidal  character  should  be 
repeated  or  maintained  for  several  days,  so  that,  not  only  the  bacteria 
themselves,  but  their  spores  also  will  be  destroyed.  There  is  probably 
nothing  in  the  whole  range  of  gynecological  therapeutics  that  is  so 
futile,  not  to  say  farcical,  as  the  repeated  applications  to  the  cervical 
membrane  of  various  medicaments  of  undetermined  antiseptic  value, 
and  many  of  them  of  unknown  ingredients.  As  a  rule  these  applica- 
tions are  made  to  a  canal  bathed  with  tenacious  mucus,  which  of  itself 
constitutes  an  efficient  protective  for  the  underlying  micro-organisms. 
Topical  treatment,  to  be  effective,  must  be  brought  into  direct  contact 
with  the  micro-organisms.  These,  as  already  described,  are  hidden  away 
within  the  epithelial  folds  or  deep  down  in  the  mucous  follicles.  The 
tissues  themselves,  both  epithelial  and  subepithelial,  are  more  or  less 
hypertrophied;  an  agent,  therefore,  which  will  be  effective  must 
modify  this  histologic  state.  Most  practitioners  have,  therefore,  aban- 
doned the  use  of  nonescharotic  agents.  Those  that  are  employed, 
however,  are  not  viciously  destructive  of  the  tissues  like  nitric  acid 
or  sulphuric  acid,  or  pure  formalin.  Reed's  method  of  treating  these 
cases  is  as  follows:  The  cervical  canal  is  dilated,  if  necessary,  to  a  very 
slight  degree  by  means  of  a  Nott  or  other  small  dilator.  The  posterior 
lip  of  the  cervix  is  seized  with  a  vol  sell  a  or  the  serrated  cervix  forceps  of 
Dumont-Lelois  and  held  by  slight  downward  traction.     The  uterine 


365  A   TEXT-BOOK  OF   GYNECOLOGY 

cavity  is  then  packed  with  a  very  slender  ribbon  of  dry  sterilized  gauze; 
this  is  immediately  withdrawn,  bringing  with  it  all  the  mucus  from 
the  endometrial  surface.  If  a  first  packing  is  not  satisfactory  for  this 
purpose,  a  second  may  be  utilized.  After  the  mucous  surfaces  have 
thus  been  carefully  cleansed,  the  uterine  cavity  is  again  packed  with 
a  slender  ribbon  of  gauze  saturated  with  98-per-cent  carbolic  acid. 
This  is  left  in  situ.  In  applying  the  carbolic  acid  it  is  important  to 
avoid  bringing  it  in  contact  with  the  integument  of  the  mucous  mem- 
brane of  the  vagina;  but  if  this  accident  should  happen,  the  place 
should  be  immediately  touched  Avith  pure  alcohol,  which  will  neutralize 
the  carbolic  acid.  A  tampon  of  glycerine  or  of  boroglyceride  is  applied 
and  the  patient  is  permitted  to  go  home,  returning  in  forty-eight 
hours  for  a  repetition  of  the  treatment.  Three  or  four  applications  of 
this  kind,  made  at  lengthening  intervals  during  ten  days,  are  generally 
sufficient  to  cure  an  ordinary  case  of  catarrhal  endometritis.  The 
treatment,  contrary  to  usual  theoretic  preconceptions,  is  not  particu- 
larly painful  and  never  requires  an  angesthetic.  The  destruction  of 
epithelium  from  these  repeated  applications  is  not  sufficient  to  inter- 
fere with  its  speedy  reproduction.  Cases  have  been  reported  in  which 
cures  have  been  effected  by  the  introduction  into  the  uterine  cavity  of 
a  piece  of  lunar  caustic,  which  was  permitted  to  dissolve  in  situ.  The 
uterine  cavity  has  been  packed  with  boric  acid  and  with  iodoform, 
both  of  which  have  some  bactericidal  properties.  Canquoin  has  re- 
ported successes  from  the  intrauterine  application  of  a  paste  the 
essential  ingredient  of  which  is  the  chloride  of  zinc.  It  is  prepared 
in  the  form  of  a  pencil  and  is  introduced  into  the  uterus;  Pichevin, 
Emmet,  Schroder,  Martin,  Munde,  Jacobs,  and  others,  have  reported 
adversely  on  its  use,  and  it  seems  to  have  been  discontinued.  As  an 
escharotic  agent,  the  chloride  of  zinc  is  vastly  more  destructive 
than  even  the  silver  nitrate,  the  use  of  which  has  been  very  generally 
abandoned. 

Sneguireff  recommended  the  action  of  steam  upon  the  inner  surface 
of  the  uterus  as  a  means  of  arresting  intrauterine  hemorrhage,  and  it 
has  been  quite  extensively  employed,  especially  in  Eussia.  Its  applica- 
tion requires  a  steam  generator  with  a  safety  valve  and  with  a  central 
opening  for  the  insertion  of  a  thermometer,  the  generator  being  con- 
nected by  rubber  tubing  with  a  metal  catheter  of  necessary  length  for 
intrauterine  application.  The  temperature  should  be  kept  between  100° 
and  110°  C.  (212°  F.  to  230°  F.).  A  Fritsch  uterine  irrigator  may  be 
used  for  the  application  of  the  steam.  The  patient  is  placed  in  the 
lithotomy  position,  and  a  short  cylindrical  speculum  of  some  noncon- 
ducting material,  such  as  celluloid  or  hard  rubber,  or  preferably  wood, 
is  inserted.  A  catheter  is  then  inserted  and  the  steam  is  turned  on. 
The  instrument  should  be  encircled  with  gauze,  or  provided  with  a 
nonconducting  handle,  to  avoid  burning  the  hands  of  the  operator. 
The  patient  should  remain  in  bed  for  a  few  days.  There  is  generally 
considerable  reaction  with  pronounced  perimetric  irritation.     It  has 


INFECTIONS  OF   THE   UTERUS  3O7 

been  recommended  by  Pincus  for  senile  endometritis  with  profuse 
hemorrhage  or  leucorrhcea;  where  irregular  hemorrhages  are  associ- 
ated with  subinvolution  of  the  uterus;  for  diffuse  myomata;  for 
hyperplastic  or  catarrhal  endometritis;  and  for  gonorrhoeal  and  strep- 
tococcous  infections  of  the  uterus.  It  must  not  be  used  in  the  presence 
of  diseased  adnexa  or  in  cases  of  stricture  of  the  cervical  canal,  while 
it  is  not  advised  in  polypoid  myomata.  This  method  is  spoken  of  as 
vaporization,  but  it  is  really  a  cauterization  with  extensive  destruction 
of  tissue.  It  is  possible  that  the  principle  may  survive,  although  the 
present  technique  seems  to  be  defective.  The  use  of  superheated 
steam  destroys  tissue  to  a  depth  that  is  dangerous.  Baruch  reports  a 
case  of  atrophy  of  the  uterus  with  occlusion  of  the  cervical  canal  and 
apparently  of  the  whole  uterine  cavity,  following  vaporization  in  a 
woman  only  twenty-seven  years  old.  This  condition  amounting  to  the 
practical  destruction  of  the  uterus  was  induced  by  a  single  intrauterine 
application  of  steam  for  the  purpose  of  checking  puerperal  hemorrhage, 
an  object  which  was  speedily  accomplished.  Von  Guerard  {Central- 
blatt  filr  Gynak-ologie)  reports  the  case  of  a  woman  who  had  persistent 
hemorrhages  following  delivery,  with  evidences  of  subinvolution  of 
the  uterus  and  fungous  degeneration  of  the  endometrium.  Atmocau- 
sis,  as  this  method  of  vaporization  is  called,  was  employed.  There  was 
a  cessation  of  the  menses  following  the  operation,  but  at  the  menstrual 
periods  unendurable  pains  were  felt,  becoming  intensified  as  time  went 
on.  The  uterine  cavity  was  so  obliterated  by  the  steam  jet  that  the 
sound  entered  it  for  about  2  centimetres  only.  Von  Guerard  was 
forced  to  relieve  the  patient  by  a  total  hysterectomy,  from  which  she 
recovered.  In  commenting  upon  the  case,  he  insists  that  atmocausis 
was  absolutely  contraindicated  before  the  menopause.  Schick,  of 
Prague  {CentraTblatt  filr  Gynakologie),  recognising  the  valuable  prop- 
erty of  heat  for  antiseptic  and  hemostatic  purposes  and  as  an  escharotic 
agent,  has  endeavoured  to  secure  its  desired  effect  by  the  use,  not  of 
superheated  steam,  but  of  boiling  water.  He  kept  up  the  irrigation 
for  half  a  minute,  only  the  vagina  and  vulva  being  protected  by  con- 
stant irrigation  of  ice-cold  water.  Of  the  four  cases  in  which  he  tried 
it  three  were  successful.  While  this  treatment  may  be  of  great  value, 
its  employment  is  certainly  associated  with  great  danger,  and  it  is 
mentioned  in  this  connection  only  with  the  hope  that  the  valuable 
principle  which  it  embodies  may  find  safe  exemplification  in  more  re- 
fined methods. 

It  may  be  stated,  as  a  rule  to  which  there  are  no  exceptions,  that 
in  all  cases  of  infection  of  the  uterus  in  which  the  condition  has 
assumed  the  chronic  form  with  associated  histologic  changes,  the 
topical  application  of  any  medicament,  escharotic  or  otherwise,  is  less 
satisfactory  than  curettage  followed  by  appropriate  antiseptic  treat- 
ment. 


368 


A   TEXT-BOOK  OF  GYNECOLOGY 


CUBETTAGE    OF    THE    ITtERUS 


Instruments  for  Dilatation  of  the 

Catheters,  glass  (Fig.  147) 1 

Catheter,  irrigating  two-way,  small. . .  1 

Curette,  sharp  (Sims's  modified) 1 

3Iartin"s  blunt,  double 1 

Martin's  sharp  (Fig.  148) 1 

Dilators,  Palmer's  medium. 

Hegar's,  4  sizes  (Fig.  149). 

Goodell-Ellinger. 
Forceps,  Bozeman's  long  dressing  (Fig. 

150) 1 

Kat-tooth 1 


Cervix  and  Curetting  of  the  Uterus 

I  Forceps,  bullet 2 

I  Serrated  cervix   forceps  of    Dumont- 

'      Leloir  (Fig.  151) 1 

Nozzle,  Edebohls's 1 

Packer,  vaginal 1 

Sound,  uterine 1 

Speculum,  Jones's  (Fig.  152) 1 

Sims's  small 1 

Simon's,  with  handles  and  four  blades 

(Fig.  153) 1 

Tenacula  (Fig.  154). 


In  those  varieties  of  intrauterine  infection  resulting  in  the  develop- 
ment of  fungous  granulations  with  associated  hemorrhage,  intra- 
uterine medication  of  whatever  sort  is  futile.  The  only 
available  remedy  consists  in  the  removal  of  the  adventitious 
tissue.  Patients  who  are  the  victims  of  hemorrhage,  and 
are  consequently  gi-eatly  reduced  in  strength,  are  generally 
less  persistent  in  urging  objection  to  the  slight  surgical  pro- 
cedure of  curettage.  This,  with  associated  antiseptic  meas- 
ures, is  distinctly  the  most  valuable  means  of  treating  infec- 
tions either  acute  or  chronic,  either  mixed  or  specific,  of  the 
endometrium;  while  if  not  followed  by  antiseptic  measures 
it  is  a  worthless  and  dangerous  expedient.  The 
uterine  curette,  according  to  Pozzi,  was  invented  by 
Eecamier,  after  which  it  fell  into  discredit.  J. 
Marion  Sims  did  much  to  re-establish  the  instru- 
ment in  favour,  while  Thomas  Eoux  and  the  elder 
^lartin  have  been  instrumental  in  defining  its  uses 
and  limitations.  The  curettes,  as  now  found,  vary 
in  size  and  form;   some  of  them  are  dull  wire  loops, 

\bent  at  various  angles;  others  are  spoon-shaped, 
some  with  dull  and  some  with  sharp  edges;  some 
are  steel  loops  with  sharp  edges,  while  others,  like 
that  recently  invented  by  Gau  (Fig.  144),  are  pro- 
vided with  a  safet)^  end,  and  yet  can  be  used  as 
either  a  sharp  or  a  dull  instrument.  All  of  them  are 
found  illustrated  in  the  instrument  makers'  cata- 
logues. The  object  of  the  curette  is  to  remove  ad- 
ventitious tissue  from  the  uterine  cavity  or  cervix.  The  method  of  its 
employment  does  not  differ  from  that  already  described  in  connection 
with  exploratory  curettage  as  a  means  of  diagnosis  in  endometritis 
(ante).  As  a  matter  of  fact,  curettage,  whether  undertaken  for  diagnos- 
tic or  other  purposes,  should  always  be  conducted  with  the  same  ante- 
cedent and  sequent  precautions.  The  same  rigorous  antisepsis  should 
precede  the  operation,  the  interior  of  the  uterus  should  be  treated  in 


Fig.  147. 

Glass 
catheter. 

EOBB. 


Fig.  148. 
Martin's 
sharp 
curette. 
— Kobe. 


INFECTIONS  OF   THE   UTERUS 


369 


precisely  the  same  way,  and  the  operation  itself  should  be  just  as  ex- 
tensive when  undertaken  for  diagnostic  as  for  other  purposes.  It  may 
be  accepted  as  an  axiom  of  practice  that  the  existence  of  any  condi- 
tion demanding  the  use  of  a  curette  can  be  determined  by  macro- 
scopic appearances;  while  the  more  refined  diagnosis  may  be  based 
upon  subsequent  examination  of  the  scrapings. 

The  first  contraindication  of  curettage  is  nonexperience  in  uterine 
surgery  on  the  part  of  the  operator.     There  is  probably  no  manipula- 


FiG.  149. — Hegar's  dilator.— Kobe. 


tion  in  surgery  for  the  proper  practice  of  which  more  dexterity,  more 
deftness,  or  more  of  that  judgment  which  depends  on  the  tactus  eru- 
ditus,  is  demanded  than  curettage.  Among  other  contraindications, 
summarized  by  Currier  {International  Journal  of  Surgery),  are  igno- 
rance on  the  part  of  the  operator  of  the  exact  limits  and  outline  of 
the  uterine  cavity;  the  presence  of  the  menstrual  flow;  extreme  dis- 
placements of  the  uterus;  and  acute  infectious  diseases  of  the  uterine 
appendages.  Polk  {New  York  Journal  of  Gynecology  and  Obstetrics) 
takes  the  ground  that  curettage  is  an  eligible  operation  in  cases  of 
chronic  metritis  associated  with  salpingitis,  asserting  that,  when  prop- 


FiG.  150. — Bozeman's  long  dressing  forceps. — Eobb. 


erly  done,  it  affords  much-needed  depletion  to  the  uterus  and  is  not 
followed  by  peritonitis  or  acute  salpingitis;  and  in  support  of  his 
statement  presents  a  tabulated  list  of  forty  cases  giving  the  maximum 
diurnal  temperature  for  eleven  days  following  the  operation.  It  is 
certainly  a  gratifying  exhibit  showing  but  trifling  and  evanescent 
reaction,  and  that  only  in  a  few  cases.  But  gratifying  as  these  facts 
are,  they  can  not  be  accepted  as  demonstrating  the  safety  of  curettage 
in  the  presence  of  inflammatory  conditions,  whether  acute  or  chronic, 
in  which  pus,  although  in  undetectable  quantities,  is  liable  to  exist 
25 


370 


A  TEXT-BOOK  OP  GYNECOLOGY 


in  the  uterine  appendages.  The  necessary  traction  and  vigorous 
manipulation  essential  to  a  thorough  curettage  is  liable  to  produce 
cleavages  in  adhesions  and  consequently  to  liberate  previously  con- 
fined pus. 

Objection  has  been  urged  against  the  use  of  the  sharp  curette  upon 
the  ground  that  it  destroys  the  epithelium  which  is  replaced  by  cica- 
tricial  tissue.      This    objection   is   not   tenable   unless   the    operation 
amounts  to   a  practical  endometrectomy  involving  the   complete  re- 
moval of  the  basis  membrane  of  the  endometri- 
um.   As  has  been  shown  by  Von  Kohlden  and 
others,    there    occurs    physiologically    in    con- 
nection   with    the    menstruation    a   periodical 
loss  of  epithelium.    This 
physiologic  function  may 
be  carried  to  the  jjatho- 
logical  degree  involving 
the  shedding  of  the  en- 
tire    membrane.       (See 
Membranous  Dysmenor- 
rhcea).      When   this    oc- 
curs,  however,   the   membrane 
is   again    speedily   reproduced. 
Bossi    has    studied   the    repro- 
duction  of  the   mucous   mem- 
brane of  the  uterus,  following 
its  apparent  complete  destruc- 
tion by  Canquoin's  paste  of  the 
chloride  of  zinc.    From  his  ob- 
servations and  a  more  or  less 
thorough  investigation  of  the 
question,  he  has  arrived  at  the 
following     conclusions     (Nou- 
velles  archives  d'obsUtrique  et  de 
gynecologie,    December,    1891): 
1.  The   mucous   membrane   of 
the  uterine  body  in  the  bitch, 
abraded  by  free  cuts  of  the  bis- 
toury   extending    through    its 
whole  thickness,  is  reproduced 
in  its  integrity,  that  is  to  say,  with  a  formation  of  true  glands.    2.  Re- 
production takes  place  slowly,  and  sometimes,  by  reason  of  conditions 
not  well  determined,  is  subject  to  considerable  retardation.     3.  The 
covering  epithelium,  which  primarily  extends  over  the  wounded  sur- 
face, derives  its  small  glands  from  the  borders  of  the  cut.     4.  The 
newly  formed  glandules  derive  from  the  proliferation  of  cells  a  new 
covering  epithelium  when  it  has  acquired  the  cylindrical  form. 

As  a  final  word  on  curettage  in  the  treatment  of  endometritis,  let 


Fig.  151. — Serrated  cervix  for 
ceps  of  Dumont-Leloir. 


Fig.  152, 
Jones's  speculum. 


INFECTIONS  OP   THE   UTERUS 


571 


it  be  said  that  the  mere  scraping  away  of  inflammatory  products  is 
curative  to  that  extent  and  to  that  extent  alone;  that  if  the  treat- 
ment stops  at  that  point  it  will  be  worthless;  that  curettage  is  not 
necessary  in  the  many  cases,  even  to  remove  these  inflammatory  prod- 
ucts; that  its  value  consists  in  removing  those  tissue  elements  which 
serve  as  hiding  places  for  the  morbific  micro-organisms;  and,  finally, 
that  the  essential  element  of  the  treatment  consists  in  the  thorough 


O 


Fig.  153. — Simon's  speculum. — Eobb. 


Fig.  154. — Tenacula. — Robb. 


application  of  antiseptic  agencies  to  the  denuded  endometrial  surface. 
Curettage  is,  therefore,  but  a  part,  although  a  very  important  part, 
of  a  plan  of  treatment  which  has  for  its  object,  not  alone  the  re- 
moval of  pathologic  products,  but  the  destruction  of  the  causative 
bacteria  and  their  spores. 


CHAPTEE  XXYII 

INFECTIONS  OF  THE  UTERUS  (Continued) 

Specific:  Gonocoecous  infection  (gonorrhoea) — Streptococcous  infection  (puerperal 
fever) — Tuberculous  infection  (tuberculosis):  of  the  cervix:  of  the  corpus — 
Syphilitic  infection  (syphilis) — Ecliinococcous  infection  (hydatids). 

Gonococcous  infection  of  the  uterus  is  simply  an  upward  extension 
of  gonorrhoea  from  the  vagina.  This  rarely  occurs  spontaneously,  be- 
cause of  the  resistance  offered,  first,  by  the  mechanical  arrangement 
of  the  vagina,  and  next,  by  its  secretions  and  its  normal  bacteria, 
notably,  the  acid-secreting  bacillus  of  Doderlein.  (See  Gonorrhoea  of 
the  External  Genitalia.)  Extension  to  the  uterus  in  the  majority  of 
cases  is  the  result  of  mechanical  intervention  in  some  form.  As 
pointed  out  by  Eosenwasser,  it  often  results  from  meddlesome  treat- 
ment of  the  disease  when  limited  to  the  vulva.  Some  physicians  pro- 
ceed upon  the  mistaken  theory  that  the  vagina  is  the  primary  seat 
of  infection  of  gonorrhcea  in  woman,  and  begin  at  once  to  treat 
that  canal  with  mistaken  vigour.  The  ordinary  result  of  such  inter- 
ference is  to  establish  the  very  condition  which  it  is  desired  to 
overcome.  It  must  be  admitted,  however,  that  in  the  majority  of 
cases,  the  patient  herself,  rather  than  her  physician,  is  responsible  for 
the  extension  of  the  infection.  The  practically  universal  use  of  the 
vaginal  douche  results  in  these  cases  in  mischievous  complications. 

Schultze  investigated  two  hundred  cases  with  the  result  that  he 
disj)roved  the  accuracy  of  Broese's  opinion  that  the  uterus  is  infected  in 
every  case  of  gonorrhoea  in  women.  Schultze  further  concluded  that 
gonorrhoea  is  infectious  only  until  the  gonococci  have  disappeared  from 
the  secretion,  whether  the  latter  is  vitreous  or  purulent;  he  found 
that  when  the  cervical  secretion  contains  no  gonococci  there  are  none 
in  the  secretion  from  the  cavity  of  the  uterus.  The  secretion  was 
purulent  in  a  trifle  over  50  per  cent  of  the  cases,  while  in  the  rest 
it  was  vitreous  and  merely  turbid,  the  latter  conditions  not  excluding 
the  existence  of  gonococci.  The  gradual  upper  extension  of  the  in- 
fection was  indicated  by  the  fact  that  even  when  the  cervix  was 
involved,  the  uterus  showed  contamination  in  only  38  per  cent  of 
the  cases.  The  adnexa  suffered  in  38  per  cent  of  those  with  cervical 
gonorrhcea,  and  in  45  -pev  cent  when  the  uterus  also  was  infected. 
Yan  Schaick  (Neiv  YorJc  Medical  Journal)  made  a  study  of  gonorrhoea 


INFECTIONS  OF   THE    UTERUS  373 

in  married  women  and  found  gonococci  existing  as  at  least  complicating 
causes  of  leucorrhoea  which  apparently  depended  upon  cervical  lacera- 
tions. 

The  symptoms  of  gonococcous  infection  of  the  uterus  do  not  differ 
materially  from  those  which  have  been  described  in  connection  with 
the  recognised  mixed  infections.  (See  Endometritis.)  The  diagnosis, 
however,  depends  upon  the  demonstrated  existence  of  the  gonococcus; 
with  the  gonococc^is  present  there  is  gonorrhoea;  without  it  there  is 
no  gonorrhosa.  Neisser  observes  that  many  cases  of  undoubted  gon- 
orrhoea would  escape  recognition  if  clinical  evidences,  alone,  were  re- 
lied upon.  The  gonococcus  is  not  always  easily  found.  Van  Schaick, 
in  a  careful  examination  of  sixty-five  women,  found  gonococci  seven- 
teen times,  or  in  36  per  cent  of  the  cases.  Nineteen  women  were 
examined  twice,  and  in  three,  gonococci  were  found  at  the  second 
examination.  Thirty-two  were  examined  three  times,  and  in  three 
of  these  the  third  examination  revealed  the  presence  of  the  micro- 
organisms. It  is  of  imjoortance  in  this  connection  to  note  the  con- 
clusion of  Broese  and  Schiller  (Berliner  Minisclie  Wochenschrift)  that 
the  intercellular  arrangement  of  gonococci  is  not  to  be  recognised 
as  pathognomonic  of  acute  gonorrhoea,  since  they  have  repeatedly  found 
them  outside  the  cells.  The  diagnosis  of  chronic  gonorrhoea,  these 
observers  contend,  may  be  based  upon  the  characteristic  shape  and  size 
of  the  gonococci,  and  upon  their  reaction  to  the  Pick-Jacobson  method 
of  staining.  The  history  of  a  previous  acute  attack  of  vulvar  and 
urethral  gonorrhoea,  particularly  if  treated  with  douches  and  tampons, 
is  a  clinical  factor  of  conclusive  diagnostic  importance.  In  the  puer- 
peral state,  gonococcous  infection  of  the  uterus  is  manifested  by  an 
increase  in  the  volume  of  the  lochial  discharge,  which  becomes  puru- 
lent but  not  necessarily  offensive.  The  purulent  character  of  the 
lochia  is  observed  as  early  as  the  fourth  day  after  delivery.  Kronig 
has  observed  a  temperature  of  104°  F.,  or  more,  resulting  from  these 
germs  in  the  uterus.  The  occurrence  of  ophthalmia  neonatorum  in 
the  child  is  a  confirmatory  evidence  of  gonorrhoeal  infection.  The 
final  diagnosis,  however,  depends  upon  the  demonstration  of  the  char- 
acteristic micro-organisms  in  the  lochia. 

The  'pathology  of  gonorrhoeal  infection  of  the  uterus  has  but  few 
points  at  variance  from  that  of  the  other  infections.  It  would  seem 
that  the  micro-organism  reaches  the  cervical  mucosa  in  a  condition 
of  reduced  virulence,  but  sufficiently  potent  to  cause  the  usual  in- 
flammatory phenomena.  Its  behaviour  in  the  endometrium  does  not 
differ  materially  from  that  in  other  mucous  membranes.  In  the  acute 
form  the  micro-organisms  may  or  may  not  penetrate  the  cells,  and, 
as  has  been  already  stated,  their  extracellular  existence  is  not  in- 
consistent with,  true  gonorrhoeal  infection.  If  the  infection  is  received 
during  the  course  of  pregnancy  it  is  liable  to  cause  miscarriage,  with 
a  probable  upward  extension  of  the  disease  to  the  Fallopian  tubes,  as 
has  been  demonstrated  by  Wertheim.    Madleur  (Centralhlatt  fiir  Gynd- 


374  A  TEXT-BOOK  OF  GYNECOLOGY 

hologie)  has  shown  that  in  the  j)i-^erperal  state  gonococci  may  pene- 
trate the  miiscularis  and  cause  parenchymatous  suppuration;  and  that 
from  this  point  the  infection  may  reach  the  system  through  the  lymph 
channels  and  cause  arthritis,  endocarditis,  etc.  In  these  eases,  how- 
ever, the  infection  is  probably  associated  with,  if  not  dominated  by, 
Streptococcus  pyogenes.  Leleneff  (Wiener  Minisclie  Woche^ischrift)  has 
confirmed  the  observations  of  Madleur,  as  he  has  demonstrated  the 
gonococci  between  the  bundles  of  muscular  fibres.  He  states,  in  addi- 
tion, that  the  destructive  action  of  the  gonococci  upon  cellular  proto- 
plasm causes  the  latter  to  degenerate  and  liquet}',  leaving  only  a 
feebly  staining  vacuolated  nucleus.  In  view  of  the  fact  that  these 
changes  have  been  observed  alike  in  those  cells  which  contain  the 
gonococci  and  those  which  do  not,  it  is  assumed  that  the  destructive 
action  must  be  due  to  some  toxines  produced  b}^  the  gonococci.  The 
widely  credited  power  of  gonococci  to  penetrate  the  leucocytes  is  con- 
firmed, while  it  is  also  demonstrated,  contrary  to  previous  opinions,  that 
they  invade  squamous  as  well  as  columnar  epithelium,  and  that  it  is 
by  virtue  of  this  fact  that  they  find  their  way  into  the  deep  struc- 
tures of  the  uterus. 

The  treatment  of  the  acute  stage  should  be  conducted  with  refer- 
ence to  avoiding  unnecessary  diffusion  of  the  infection.  As  has  been 
shown  by  observations  already  alluded  to,  infection  may  exist  in  the 
cervical  canal  without  its  extension  to  the  corpus  uteri.  This  fact 
is  to  be  held  in  mind  in  the  adoption  of  treatment.  The  cervical 
canal  should  be  thoroughly  cleansed  and  treated  with  protargol,  a 
proteid  compound  of  silver.  Neisser  looks  upon  this  agent  as  an  effi- 
cient antigonorrhoeal  remedy,  which,  if  employed  at  an  early  period, 
exerts  a  prompt  and  favourable  influence  upon  the  course  of  the 
disease.  In  most  cases  it  arrests  all  acute  manifestations,  causing 
rapid  disappearance  of  the  secretion  and  the  gonococci,  and  prevent- 
ing the  extension  of  the  disease.  Salochin  has  used  this  remedy  in 
a  5-per-cent  solution  applied  through  a  speculum  to  the  cervical 
canal.  The  vagina  was  treated  with  a  2-per-cent  solution,  and  a 
tampon  moistened  with  it  was  left  in  position.  The  solution  made 
by  Colombeni  is  as  follows:  Ten  grammes  of  protargol  are  placed  in 
a  small  mortar  to  which  are  added  5  cubic  centimetres  of  neutral 
glycerine,  the  two  being  stirred  together  with  a  glass  rod  till  a  thor- 
oughly homogeneous  moist  paste  is  produced.  This  is  next  diluted 
with  95  cubic  centimetres  of  cold  sterilized  water,  and  shaken 
up  till  a  perfect  solution  is  produced;  this  solution  is  kept  in  a  col- 
oured bottle  in  a  dark  place.  As  required,  a  0.25-per-cent  solution 
is  made  by  mixing  2.5  cubic  centimetres  of  the  standardized  solution 
with  97.5  cubic  centimetres  of  sterilized  water;  a  0.50-per-cent  solution 
by  mixing  5  cubic  centimetres  with  95  cubic  centimetres  of  water;  a 
1-per-cent  by  mixing  10  cubic  centimetres,  and  a  2-per-cent  by  mix- 
ing 20  cubic  centimetres  of  the  standardized  solution  with  90  and  80 
cubic  centimetres,  respectively,  of  sterilized  water.     A  very  good  way 


INFECTIONS  OF   THE  UTERUS  375 

to  use  the  Colombeni  solution  is  to  saturate  a  ribbon  of  sterilized  gauze 
with  it  and  insinuate  it  into  the  uterus.  The  uterine  packing  at  this 
time,  whether  of  protargol,  pure  carbolic  acid,  or  pure  lysol,  exercises 
a  profound  bactericidal  influence,  and  does  not  carry  the  infection 
upward  into  the  uterus,  for  the  reason  that  any  micro-organism  that 
may  come  in  contact  with  the  saturated  gauze  will  be  destroyed.  The 
gauze  should  be  removed  after  forty-eight  hours,  and  should  be  re- 
placed after  an  interval  of  another  forty-eight  hours.  In  cases  of 
chronic  gonorrhoeal  infection  of  the  uterus,  the  cocci  have  found 
hiding  places  in  deep  folds  of  the  endometrium,  whence  the  disease 
has  been  looked  upon  by  some  observers  as  self -limiting,  while  others 
with  equal  emphasis  insist  that  it  is  more  or  less  constantly  revived. 
It  is  a  matter  of  clinical  observation  that  in  these  cases  there  occur 
periods  of  quiescence,  followed  by  exacerbations  that  are  not  induced 
by  fresh  infections. 

Jadassohn  (Correspoiidenz-hlatt  filr  Schtveizer  Aerzte)  asserts  that 
chronic  gonorrhoea  in  certain  cases  may  become  acute  through  super- 
infection with  their  own  cocci.  He  reaches  this  conclusion  notwith- 
standing the  observation  of  Wertheim,  that  a  mucous  membrane 
affected  with  chronic  gonorrhoea  did  not  react  to  cultures  taken 
directly  from  it,  although  it  reacted  to  cultures  taken  from  another 
patient. 

The  mucous  membrane  does  not  become  so  used  to  the  presence 
of  the  cocci  that  the  latter  can  live  as  saprophytes  on  it  after  the 
tissue  has  become  normal.  On  the  contrary,  the  inflammation  re- 
mains for  a  time  after  the  infectious  elements  have  disappeared.  He 
concludes,  also,  that  chronic  gonorrhoea  may  become  acute,  not  only 
through  the  increase  of  its  own  gonococci,  but  by  reinoculation  from 
another  person.  While  there  are  instances  in  which  the  membrane 
does  not  react  to  inoculation  with  gonococci  from  any  source  what- 
ever, they  are  to  be  looked  upon  as  exceptional,  and  the  generally 
entertained  theory,  that  the  mucous  membrane  that  has  been  the  seat 
of  a  chronic  gonorrhoea  thereby  acquires  immunity,  is  to  be  abandoned. 
It  is  not  proper,  therefore,  to  look  upon  chronic  gonorrhoea  of  the 
uterus  as  a  self-limiting  disease,  but  rather  as  one  that  is  capable 
of  indefinite  perpetuation.  Treatment  should,  therefore,  be  directed 
to  the  eradication  of  the  infection,  which,  if  left  to  itself,  will,  in 
at  least  50  per  cent  of  the  cases,  extend  upward  into  the  Fallopian 
tube.  If  this  has  not  already  taken  place,  and  if  there  is  no  acute 
infection  in  the  adnexa  or  other  perimetric  structure,  curettage  should 
be  practised.  (See  Curettage.)  The  treatment  should  in  no  wise  differ 
from  that  already  prescribed  for  chronic  infectious  endometritis,  with 
the  exception  that  it  is  better  to  select  some  distinctly  antigonorrhoeal 
remedy,  such  as  protargol,  carbolic  acid,  or  lysol,  with  which  to 
pack  the  uterus  after  its  cavity  has  been  scraped.  This  is  not  a 
dangerous  procedure  when  done  skilfully  and  under  proper  antiseptic 
precautions,  all  alarmist  declarations  to  the  contrary  notwithstanding. 


376  ^         ^   TEXT-BOOK  OF  GYNECOLOGY 

Streptococcous  Infection. — Puerperal  fever  is  the  ordinary  clinical 
manifestation  of  uterine  infection  by  the  Streptococcus  pyogenes — other- 
wise known  as  the  micrococcus  of  erysipelas.  Streptococcus  erysipelatos. 
Streptococcus  tongus,  etc.     (See  Streptococcus  Pyogenes.) 

As  elsewhere  stated,  Oliver  Wendell  Holmes  Avas  the  first  to  direct 
attention  to  the  relationship  of  cause  and  effect  between  erysipelas 
and  puerperal  fever,  an  observation  which  was  confirmed  by  Stille, 
who  reported  ninety-five  cases  of  puerperal  fever  occurring  in  rapid 
succession  in  the  practice  of  a  single  physician  in  Philadelphia,  in 
which  fifteen  of  the  children  died  from  erysipelas.  Fehleisen  was  the 
first  to  demonstrate  that  the  Streptococcus  pyogenes  was  the  essential 
micro-organism  of  erysipelas.  That  this  same  micro-organism  is  the 
materies  morbi  by  which  the  parturient  woman  is  infected  with  re- 
sulting puerperal  fever  is  supported  by  cumulative  evidence.  Clivio 
and  Monti  demonstrated  its  presence  in  five  cases  of  puerperal  peri- 
tonitis; Widal  found  it  in  sixteen;  Czerniewski  found  it  in  the  lochia 
of  thirty-five  out  of  eighty-one  women  with  puerperal  fever.  Bumm  was 
able  to  find  the  streptococci  alone  in  five  cases  (three  of  these  end- 
ing fatally).  In  twelve  cases,  besides  the  streptococci,  there  were  ob- 
served upon  the  plate  cultures  staphylococci  and  other  germs.  In 
eight  cases  the  number  of  germs  of  decomposition  were  very  great 
(mixed  form  of  septic  and  putrid  endometritis).  Two  of  these  cases 
terminated  fatally,  the  streptococci  entering  the  venous  thrombi  at 
the  placental  site  and  a  pyamiia  resulting. 

Occasionally  we  may  find  pyogenic  staphylococci,  especially  the 
aureus,  besides  the  streptococci.  Bumm  only  observed  staphylococci 
alone  in  two  cases.  The  cases  were  mild  ones,  and  this  coincides  with 
the  observations  of  Fehling. 

The  pathology  of  infection  by  the  Streptococcus  pyogenes  is  typically 
manifested  in  the  uterus.  This  micro-organism,  introduced  into  the 
vagina  by  the  finger  of  the  accoucheur  or  upon  instruments  em- 
ployed in  delivery,  finds  in  the  fluid  contents  of  the  uterus  a  congenial 
culture  medium  in  which  it  propagates  with  great  rapidity.  The 
placental  site  serves  as  an  enormous  infection  atrium,  the  wide,  dis- 
tended lymphatics  and  the  open  blood  vessels  alike  serving  as  portals 
for  the  reception  of  the  poison,  which  is  speedily  transported  thence 
to  the  general  system.  In  the  uterine  structure,  however,  is  mani- 
fested the  characteristic  action  of  the  streptococci.  As  soon  as  they 
invade  the  vessels  of  the  uterus  they  produce  changes  Avhich  break 
down  the  endothelium  and  result  in  the  development  of  a  thrombus. 
After  a  while,  the  thrombus  in  turn  breaks  down,  and  the  emboli 
thus  formed  spread  the  organisms  in  various  directions.  Many  of  them 
lodge  in  the  immediately  adjacent  vessels  of  the  myometrium,  while 
others,  gaining  access  to  the  systemic  circulations,  sanguiferous  and 
lymphatic,  are  conveyed  to  distant  organs  and  structures,  where  they 
become  foci  of  secondary  suppuration.  In  the  uterus  itself,  however, 
there  are  speedily  established,  either  primarily  or  secondarily,  similar 


INFECTIONS   OF   THE   UTERUS  377 

foci  of  suppuration,  by  which  the  organ  may  become  converted  into 
what  may  be  described  as  an  aggregation  of  small  abscesses.  The 
individual  accumulations  of  pus  may  vary  from  a  few  drops  to  a 
drachm  or  even  more.  Occasionally  two  or  more  of  these  centres 
of  suppuration  may  coalesce,  forming  a  larger  abscess  cavity.  It  should 
be  borne  in  mind  that  these  suppurative  changes  occur  in  the  myo- 
metrium, and  that  the  condition  is  essentially  one  of  interstitial  sup- 
purative metritis.  The  invasion  of  the  lymph  spaces  by  the  strepto- 
coccus results  very  speedily  in  the  development  of  an  acute  septic 
lymphangeitis,  involving  the  lymphatics,  first,  of  the  pelvis,  and,  sub- 
sequently, of  the  remoter  parts  of  the  system.  The  lymphatic  glands 
may,  themselves,  become  foci  of  suppuration.  It  should  be  remem- 
bered, however,  that  the  streptococci  do  not  produce  suppuration  so 
promptly  as  do  the  staphylococci,  and  that,  consequently,  in  the  cases 
under  consideration,  pus  does  not  appear  in  the  uterine  structures  at 
once.  In  the  earlier  stages  of  the  infection  there  occurs  simply  a 
diffuse  infiltration  of  the  tissues,  which,  if  incised,  will  set  free  a 
clear  yellowish  fluid  in  which  are  a  few  pus  cells.  As  the  streptococci 
develop,  however,  they  manifest  their  characteristic  effect  of  pro- 
ducing a  coagulation  necrosis,  which  becomes  the  focus  of  suppura- 
tion. In  the  course  of  a  few  days,  a  parturient  uterus  which  is 
the  seat  of  this  infection  may  vary  in  length  from  15  to  18  centi- 
metres, and  in  fundal  width  from  12  to  15  centunetres.  The  uter- 
ine wall  at  the  fundus  is  about  3  centimetres  in  thickness.  When 
cut  open,  the  interior  of  the  uterus  above  the  cervical  canal  is 
covered  with  a  dark  tenacious  mucus,  which  is  very  offensive.  The 
placental  site  is  distinct,  and  may  contain  fragments  of  firmly  attached 
placenta.  The  incised  myometrium,  as  in  Cartledge's  cases  {Trans- 
actions of  the  Southern  Surgical  and  Gynecological  Society),  reveal 
numerous  small  discrete  abscesses  varying  in  size  from  a  millet  seed 
to  a  large  pea.  This  description  of  the  general  macroscopical  appear- 
ance is  based  upon  examination  of  the  uterus  removed  by  vaginal 
hysterectomy  during  the  course  of  the  disease,  and  does  not,  therefore, 
depend  upon  post-mortem  changes  for  any  of  the  peculiarities  recorded. 
Bumm  (Archiv  filr  Gynakologie)  has  made  careful  studies  of  the 
endometrium,  when  the  seat  of  puerperal  infection,  and  agrees  with 
Vidal  that  this  structure  is  the  avenue  of  ingress  for  the  pathogenic 
micro-organisms  that  cause  the  disease.  From  the  endometrium  they 
enter  the  system  in  two  ways,  viz. :  first,  through  venous  thrombi,  which 
carries  them  directly  into  the  circulation,  and,  secondly,  through  the 
lyniph  channels  where  they  may  either  lodge  in  the  lymphatic  glands 
themselves  or  develop  foci  of  suppuration  in  connective  tissue.  Kehrer 
classifies  puerperal  enclometritis  into  putrid  and  septic.  In  putrid 
endometritis,  he  asserts  that  saprophytic  micro-organisms  cause  a 
change  in  the  decidua,  in  which  septic  germs  do  not  develop.  This 
change,  he  contends,  affects  only  the  uppermost  layer  of  the  decidua, 
which  is  exfoliated  as  the  new  mucous  membrane  forms  beneath  it. 


378  A  TEXT-BOOK  OF  GYNBCOLOGY 

These  changes,  he  considers,  are  manifested  by  fever  and  other  symp- 
toms of  intoxication  due  to  decomposition.  Ivehrer,  however,  admits 
that  saprophytic  infection  is  exceedingly  rare,  and  that  in  the  majority 
of  cases  of  endometritis  following  abortions  and  labours,  bacteriologi- 
cal examination  reveals  the  presence  of  septic  micro-organisms,  espe- 
cially streptococci,  and  sometimes  pyogenic  staphylococci,  so  that,  as 
already  contended  in  this  chapter,  the  cases  are  in  reality  examples  of 
mixed  infection.  In  the  histological  examination  of  a  case  of  so- 
called  putrid  endometritis  in  which,  notwithstanding  the  presence  of 
streptococci,  a  predominating  influence  seemed  to  be  exercised  by  the 
saprophytes,  the  following  histologic  conditions  were  observed:  the 
superficial  layer  of  the  decidua  was  filled  with  micro-organisms,  among 
which  were  all  forms  of  rods,  long  threads,  and  cocci  of  all  sizes. 
Fungi  were  found  growing  in  colonies  entirely  covering  the  base  of  the 
decidua.  The  tissues  were  found  in  a  state  of  necrosis,  glassy  and 
cloudy,  at  a  point  0.1  millimetre  beyond  the  area  occupied  by  the  fungi. 
The  granules  could  not  be  stained.  Beyond  the  zone  of  infection  a 
zone  of  cellular  infiltration  had  formed.  Numerous  small  round  cells 
were  observed  which  looked  like  colourless  blood  corpuscles  and  formed 
a  layer  0.3  to  0.5  millimetre  thick;  they  were  lying  close  together. 
The  zone  of  cellular  infiltration  occupied  a  position  between  the  super- 
ficial area  of  infection  and  the  muscularis.  The  fibres  of  the  myome- 
trium, however,  were  found  occasionally  to  be  separated  in  places  by 
an  accumulation  of  cells,  but  this  condition  did  not  penetrate  deeply 
into  the  muscularis.  The  round-celled  infiltration,  according  to  Bumm, 
must  be  looked  upon  as  an  effort  on  the  part  of  ISTature  to  set  up 
a  granular  wall  to  act  as  a  barrier  against  the  entrance  of  the  germs, 
and  thus  to  separate  the  dead  from  the  healthy  tissue.  The  fact,  how- 
ever, that  neither  Bumm  nor  Ivehrer  have  succeeded  in  demonstrating 
the  existence  of  this  so-called  putrid  endometritis,  independently  of 
the  existence  of  streptococci  in  large,  if  not  in  preponderating  num- 
bers, indicates  that  the  efi^ort  to  establish  a  variety  of  infection  depend- 
ing upon  the  existence  and  the  action  of  the  saprophytes  is  not  war- 
ranted by  the  facts.  This  becomes  the  more  apparent  when  considera- 
tion is  given  to  the  histological  appearances  of  what  Ivehrer  and  Bumm 
designate  as  septic  endometritis.  The  mucous  membrane  in  these 
cases  is  necrotic  and  reveals  the  remains  of  the  spongy  layer,  thor- 
oughly covered  with  streptococci  yielding  pure  cultures.  The  cocci 
occur  in  thin  layers,  while  in  other  places  they  appear  as  large  colonies 
occupying  considerable  areas.  There  is  a  reaction  zone,  less  pro- 
nounced but  none  the  less  persisting,  just  as  defined  as  in  the  putrid 
variety.  The  protection,  however,  thus  afforded,  seems  to  be  less  com- 
plete, as  there  are  fewer  round  cells,  and  the  necrotic  zone  disappears 
into  the  neighbouring  tissues  without  showing  any  sharply  defined 
boundary.  In  these  situations  the  streptococci  grow  and  penetrate 
deeply  into  and  through  the  strise  of  the  myometrium.  The  muscular 
tissue  itself  reveals  an  opacity  in  the  presence  of  large  accumulations 


INFECTIONS  OF   THE   UTERUS  379 

of  cocci.  Where  these  accumulations  occur,  they  are  surrounded  by 
small  collections  of  round  cells;  in  some  places  the  lymph  spaces  are 
filled  with  cocci,  while,  at  the  placental  site,  the  venous  spaces  are 
closed  and  contain  neither  thrombi  nor  cocci.  A  few  venous  branches 
near  the  surface,  however,  contain  blood  clots  which  inclose  a  few  of 
the  cocci.  An  extension  of  the  infection  from  the  surface  into  the 
lymph  spaces  is  demonstrable  in  numerous  sections.  Some  of  the  finer 
lymph  spaces  show  a  delicate  fungus  border  on  their  walls,  while 
others  are  empty  or  filled  with  granular  material.  When  the  infection 
occurs  within  the  lymph  channel,  it  does  not  seem  to  provoke  reaction 
in  the  surrounding  structures.  In  other  locations,  the  lymph  spaces 
are  filled  with  fungi,  while  the  cocci  are  observed  in  the  surrounding 
tissues.  In  still  other  places,  the  lymph  channels  are  filled  with  cocci, 
whence  the  fungi  spread  beyond  the  necrotic  muscular  layer,  pro- 
voking a  reactionary  accumulation  of  cells  in  the  adjacent  tissues. 
The  inflammation,  thus  centring  about  difi^erent  foci,  may  result  in  the 
liquefaction  of  the  entire  infected  mass,  changing  it  into  an  abscess 
cavity.  Bumm  raises  the  important  question:  How  can  we  explain  the 
fact  that  the  affection  sometimes  remains  local,  while  in  other  cases  it 
invades  the  lymph  channels  or  the  veins?  His  answer  is  that  the 
bacteria  must  explain  this.  They  are  beyond  question  the  agents 
which  produce  this  form  of  disease.  The  danger  exists,  not  in  their 
number,  but  in  their  virulence.  In  making  this  statement  he  simply 
emphasizes  the  observations  of  Vidal  and  Chantemesse.  In  the  local 
septic  infection,  and  in  the  thrombotic  forms,  the  germs  are  only 
mildly  virulent  and  are  made  harmless  by  the  speedy  reaction  that 
occurs  in  the  organism.  On  the  other  hand,  the  extremely  virulent 
germs  penetrate  the  walls  of  the  uterus  and  there  is  no  local  reaction. 
The  germs  occurring  in  the  lymphatic  form  he  would  place  midway  in 
virulence  between  the  extremely  virulent,  or,  as  he  expresses  it,  the 
internal,  puerperal,  erysipelatous  form,  and  the  mild,  local  or  throm- 
botic forms.  In  view  of  these  facts  and  of  the  practical  identity  in 
character,  if  not  in  degree,  of  the  pathologic  changes,  and  in  view  of 
the  demonstrated  common  etiology,  all  of  which  is  at  least  inferentially 
admitted  by  Bumm,  there  can  hardly  be  said  to  exist  any  substantial 
reason  for  discriminating  between  the  different  varieties  of  infection 
as  they  are  manifested  in  puerperal  fever.  On  the  other  hand,  the 
evidence  seems  to  be  cumulative  that  this  infection  should  be  recog- 
nised as  depending  for  its  essential  characteristics  upon  the  Strepto- 
coccus pyogenes,  and  that  occasional  modifications  due  to  the  presence, 
in  varying  proportion,  of  saprophytes  and  other  micro-organisms, 
should  be  recognised  as  incidental  rather  than  essential  variations. 

It  is  important  to  remember  that  infection  which  may  invade  the 
lymph  channels,  may  travel  through  those  highways  to  the  peritoneal 
surface,  occasioning  thereby  a  true  infection  of  the  peritoneum.  It 
has  been  stated  that  in  parenchymatous  suppuration  of  the  uterus  the 
infection  may  penetrate  directly  through  the  tissues  to  the  peritoneal 


380  ^  TEXT-BOOK  OF  GYNECOLOGY 

surface;  but,  be  this  as  it  may,  the  fact  remains,  that  streptococcous 
infection  of  the  interior  of  the  uterus  is  speedily  followed  in  many 
cases  by  involvement  of  the  peritoneum.  When  infection  of  the  peri- 
toneum takes  place,  the  serous  secretion,  which  is  copiously  thrown  out, 
becomes  a  culture  medium  for  the  rapid  reproduction  of  the  strepto- 
cocci, which  are  rapidly  absorbed  thence  by  the  numerous  stomata  of 
the  peritoneum.  Puerperal  peritonitis  is,  therefore,  always  associated 
with  profound  systemic  intoxication.  Another  avenue  by  which  the 
infection  may  reach  the  peritoneum  is  that  of  the  Fallopian  tube, 
which  is  frequently  invaded  by  the  progressive  contamination  of  con- 
tiguous mucous  surfaces.  As  a  rule,  however,  the  moment  that  septic 
inflammation  is  established  within  the  Fallopian  tube,  the  distal,  or 
fimbriated,  extremity  becomes  sealed,  thus  converting  the  tube  into 
a  sort  of  retention  cyst.  Leakages  may  occur,  however,  particularly 
when  the  tubal  distention  has  resulted  in  rupture. 

The  symptoms  of  streptococcous  infection  of  the  uterus  begin  with 
a  chill,  which  may  or  may  not  be  preceded  by  fever.  The  temperature 
reaction,  however,  which  follows  the  initial  chill  is  generally  severe. 
The  lochia  which,  up  to  this  time  may  have  been  normal  in  quan- 
tity, colour,  odour,  and  consistence,  are  temporarily  checked,  become 
darker  in  colour,  more  viscid,  and  have  an  offensive  odour.  The  ther- 
mic range  now  becomes  characteristically  irregular.  Another  chill, 
which  may  be  either  slight  or  severe,  is  followed  by  a  profuse  perspira- 
tion, generally  of  a  clammy  character,  succeeded  by  marked  exhaus- 
tion. The  chills  now  become  irregular,  recurring  either  daily,  or 
sometimes  skipping  a  day;  in  which  case  two  or  three  chills  may 
occur  in  the  course  of  12  or  24  hours,  being  then  followed  by  an- 
other interval  of  immunity.  The  chills  are,  however,  more  prone 
to  occur  during  the  evening  or  the  night  than  in  the  morning  or  after- 
noon. The  fever  curve  may  show  an  evening  exacerbation  followed 
by  a  morning  remission,  as  in  certain  forms  of  malarial  toxaemia,  but, 
as  a  rule,  the  vacillation  is  of  a  very  lawless  kind.  As  a  rule,  the  first 
febrile  manifestation  amounts  to  three  or  four  degrees;  after  this,  there 
is  a  slight  remission  involving  a  drop  of  one  or  two  degrees;  then  a 
slight  rise  and  a  slight  fall.  The  rise  rarely  reaches  the  original  eleva- 
tion and  the  fall  never  approximates  the  normal  line.  In  the  course  of 
eight  or  nine  days,  however,  it  will  be  discovered  that  the  vacillations 
are  a  little  more  pronounced — i.  e.,  the  elevations  are  a  little  higher 
and  the  depressions  a  little  lower  than  formerly,  while  the  vacillations 
occur  with  greater  frequency  than  before.  There  seems  to  be  a  con- 
stant tendency  for  the  highest  and  lowest  points  to  get  farther  and 
farther  apart.  There  are,  of  course,  individual  exceptions  to  the  rule 
Just  given.  In  the  presence  of  a  particularly  virulent  infection  the 
initial  chill  may  be  very  profound,  the  elevation  of  temperature  may 
be  high  and  may  so  continue  during  the  course  of  the  disease,  showing 
but  very  slight  remissions.  The  cardiac  centres  are  early  influenced 
by  the  infection,  the  pulse  rising  to  120,  or  higher,  and  being  generally 


INFECTIONS  OP   THE  UTERUS  381 

soft  and  compressible.  The  respiration  is  rajnd,  the  tongue  speedily 
becomes  coated,  generally  with  a  white  fur,  though  ordinarily  moist. 
There  is  not,  as  a  rule,  marked  disturbance  of  digestion,  particularly 
to  the  degree  which  occurs  in  septicaemia.  As  the  disease  advances, 
however,  the  patient  becomes  emaciated  and  anxious,  and  delirium 
may  supervene,  although  in  some  cases  the  intelligence  remains  intact 
until  a  short  time  before  death. 

The  diagnosis  of  streptococcous  infection  of  the  uterus  is  made, 
first,  by  a  careful  estimation  of  the  preceding  symptoms;  and,  subse- 
quently, by  detection  of  the  streptococcus.  A  curette  or  a  curette 
forceps  may  be  passed  into  the  uterus,  when  some  of  the  debris  of 
degeneration  can  be  removed.  Microscopic  and  bacterial  examination 
of  the  scrapings  will  reveal  the  presence  of  the  Streptococcus  pyogenes 
but  in  association,  perhaps,  with  other  micro-organisms.  It  will,  how- 
ever, be  found  in  such  preponderating  numbers  that  the  essential 
character  of  the  infection  can  not  be  mistaken.  A  drop  of  blood  taken 
from  the  tip  of  the  finger  or  from  the  ear  will  reveal  the  presence  of 
the  streptococcus  and  blood  plaques  in  the  presence  of  a  pronounced 
leucocytosis.  The  red  corpuscles  are  diminished  in  number,  many  of 
them  presenting  a  shrunken  appearance. 

The  treatment  of  streptococcous  infection  of  the  uterus  must  have 
a  threefold  object,  namely,  (1)  to  arrest  the  infection,  if  possible,  at 
its  point  of  entrance;  (2)  to  eliminate  the  poison  from  the  system  after 
the  invasion  has  passed  beyond  the  point  of  entrance;  and,  (3)  to 
support  the  patient  during  the  course  of  the  pyasmic  sequelas  of  the 
infection. 

A  moment's  consideration  of  the  pathology  of  this  infection  renders 
it  unnecessary  to  emphasize  the  importance  of  prompt  intervention  to 
arrest  the  infection.  The  first  signs  of  temperature  disturbance, 
whether  an  initial  chill  followed  by  fever,  or  an  initial  pyrexia  with- 
out a  chill,  associated  with  a  change  in  the  quantity,  colour,  and 
odour,  of  the  lochia,  should  be  the  signa,!  for  a  careful  exploration  of 
the  uterus.  If,  from  examination,  the  fact  is  determined  that  the 
symptoms  are  of  intrauterine  origin,  there  should  be  no  hesitancy  in 
practising  thorough  curettement  under  the  most  rigorous  antiseptic 
precautions.  With  reference  to  the  use  of  the  curette  under  these 
circumstances  much  unnecessary  dispute  has  arisen.  Those  who  ques- 
tion the  expediency  of  its  employment  apparently  fail  to  take  into 
account,  either  the  character  of  the  infection,  or  the  primary  patho- 
logic changes  which  it  induces.  The  formation  of  thrombi  in  the 
orifices  of  the  veins  in  the  placental  site  is,  of  itself,  sufficient  to 
materially  diminish  the  outflow  of  fluid  from  that  source;  while  the 
inflammatory  exudation  arrests  the  free  escape  of  serous  elements  from 
the  intervenous  areas.  At  this  juncture.  Nature  is  found  in  the  act  of 
rallying  her  resources  to  repel  the  invader,  and  there  may  be  said 
to  be  a  temporary  check  in  the  course  of  the  infection.  This  is  pre- 
cisely the  time  when  treatment,  to  be  of  the  most  value,  should  be 


382  A  TEXT-BOOK  OF  GYNECOLOGY 

applied  with  the  most  thoroughness.  The  patient  should  be  anaesthe- 
tized; placed  upon  the  table  in  the  recumbent  position;  a  Jones's,  or 
other  perineal  retractor  should  be  used;  the  vagina  should  be  thor- 
oughly irrigated;  and  the  uterus  should  be  washed  out  by  means  of  a 
recurrent  catheter.  A  sharp  curette  with  a  blunt,  protecting  edge,  like 
that  of  Gi-au's,  should  be  inserted,  and  the  uterine  wall  should  be  thor- 
oughly scraped.  If  free  bleeding  is  induced,  so  much  the  better,  as  the 
hemorrhagic  current  has  the  mechanical  value  of  washing  away  remain- 
ing elements  of  infection.  Great  care  should  be  taken  to  avoid  pene- 
tration of  the  soft  uterine  wall.  After  the  interior  of  the  uterus  has 
been  thoroughly  curetted,  the  cavity  should  be  washed  out  by  a  1-to- 
2,000  solution  of  the  mercuric  bichloride,  a  recurrent  uterine  irrigator 
being  employed  for  the  purpose.  The  uterine  cavity  should  then  be 
packed  with  a  long  ribbon  of  iodoform  gauze  saturated  with  sterilized 
glycerine.  Glycerine,  by  virtue  of  its  hygroscopic  qualities,  favours 
an  outward  current  of  transudation,  and  thus,  if  it  does  not  promote 
elimination  of  any  remaining  infection,  it,  at  least,  offers  some  barrier 
to  the  further  invasion  of  the  tissues.  The  patient  should  be  placed 
in  the  recumbent  posture  at  the  expiration  of  twenty-four  hours,  when 
the  uterine  packing  should  be  removed  and  carefully  reapplied  after 
the  uterine  cavity  has  been  again  irrigated  by  the  sublimate  solution. 
There  is  no  occasion  to  repeat  the  curettement  provided  that  it  has 
been  well  done,  and  the  patient  will  not,  therefore,  require  an  anass- 
thetic.  The  dressing  should  be  changed  at  similar  intervals  during 
three  or  four  days,  when,  if  the  temperature  range  becomes  normal, 
the  treatment  may  be  discontinued.  Some  excellent  practitioners 
employ  constant  irrigation  of  the  uterine  cavity,  instead  of  packing 
with  iodoform  or  other  antiseptic  agents,  and  very  good  results  have 
been  reported  from  this  course  of  treatment.  For  its  accomplishment 
a  reflux  uterine  irrigator,  such  as  that  devised  by  Gaither,  should  be 
used.  This  is  an  excellent  instrument,  and  secures  the  reflux  current 
by  effecting  the  dilatation  of  the  cervix  to  any  desired  degree.  It  is 
more  valuable  than  the  ordinary  tubular  instruments,  which  are  prone 
to  become  choked  by  clots  or  other  debris. 

The  object  of  curettage  is  only  half  realized  when  the  infected 
debris  has  been  scraped  away;  it  is  equally  imperative  to  asepticize,  so 
far  as  possible,  the  remaining  endometrium.  To  accomplish  this,  the 
uterus  may  be  packed  as  indicated  in  the  preceding  paragraph.  Some 
excellent  practitioners  employ  constant  drainage  with  the  best  results. 
Ill  (Transactions  of  the  American  Association  of  Obstetricians  and 
Gynecologists)  packs  the  uterus  with  iodoform  gauze,  which  is  kept 
saturated  with  an  antiseptic  medicament  applied  through  a  hollow 
curved  tube  (Fig.  155).  This  ingenious  arrangement  secures  both  an 
influx  and  an  efflux  of  fluid,  and  is  deserving  of  consideration. 

If,  however,  in  spite  of  these  precautions  the  temperature  con- 
tinues to  vacillate  and  to  show  a  characteristic  pygemic  range,  and 
particularly  if  the   pulse   goes  to   130,   with  a  tendency  to  increase 


INFECTIONS  OP  THE   UTERUS 


5  S3 


in  frequency  and  to  diminish  in  force  and  volume,  the  evidence  is 
to  be  construed  as  meaning  that  the  infection  has  invaded  the  lymph 
channels,  and  that  the  myometrium  has  become  the  seat  of  diffuse  in- 
fection, if  not  of  multiple  suppurations.  It  is  manifest  that,  under 
these  circumstances,  the  disease  has  passed  beyond  the  control  of  such 
a  conservative  measure  as  curettement.  The  condition  indicated  by 
this  persistence  of  symptoms  is  one  which,  if  left  alone,  is  calculated 
constantly  and  progressively  to  re-enforce  the  systemic  infection,  and 


Fig.  155. — "  111  packs  the  uterus  with  iodoform  gauze,  which  is  kept  saturated  with  an  anti- 
septic medicament  applied  through  a  hollow  curved  tube." — Eeed  (page  382). 


thereby  to  keep  alive  a  pyasmic  state  which  must  result  in  death.  An 
intelligent  comprehension  of  the  symptoms  and  of  the  underlying 
pathologic  conditions  can  not  result  in  any  other  conviction  than  that 
the  line  of  treatment  must  be  complete  removal  of  the  uterus.  Success- 
ful cases  of  this  character  have  been  reported  by  Vineberg,  Cartledge, 
and  others.  The  operation  may  be  done  either  through  the  vagina 
or  by  abdominal  section.  The  latter  route  is  generally  preferable, 
for  the  reason  that  the  uterus  may  be  too  large  to  be  easily  de- 
livered  through    the   vagina,   while   in   its   septic  state,   its  morcclla- 


384  A   TEXT-BOOK  OF   GYNECOLOGY 

tion  would  be  a  dangerous  expedient.  Extraordinary  antiseptic  pre- 
cautions shoiild  be  taken  in  making  an  abdominal  section  under  these 
circumstances.  The  patient  should  be  prepared  by  a  thorough  vaginal 
and  intrauterine  irrigation^  and  the  uterus  should  be  packed  with  dry 
iodoform  gauze.  It  may  not  be  amiss  to  close  the  os  externum  by 
passing  a  single  suture  through  the  anterior  and  posterior  lips  of  the 
cervix.  By  this  means  the  field  of  operation  will  be  fairly  well  pro- 
tected from  contamination.  These  preliminary  steps  should  be  taken 
by  the  assistant,  or,  if  by  the  operator  himself,  he  should  employ 
rubber  gloves  for  the  purpose.  As  soon  as  the  intravaginal  manipu- 
lations are  concluded  the  rubber  gloves  employed  at  that  time  should 
be  taken  off,  and  should  be  replaced  by  another  pair  carefully  steril- 
ized. In  this  way,  alone,  can  the  operator  feel  sure  of  giving  reason- 
able protection  to  his  patient.  The  operation  should  be  that  of  pan- 
hysterectomy, involving,  as  the  name  implies,  the  removal  of  the 
entire  uterus  with  its  appendages.  The  technique  of  the  operation 
does  not  differ  in  any  particular  from  that  described  in  the  chapter 
on  panhysterectomy.  It  is  well,  as  a  matter  of  routine,  to  practice 
hypodermoclysis  both  before  and  after  the  operation,  three  or  four 
pints  of  water  being  administered  in  this  way. 

Supporting  treatment  should  be  adopted  from  the  start,  care 
being  taken  to  preserve  the  digestive  functions,  which,  happily,  are 
not,  as  a  rule,  seriously  compromised  in  these  cases.  Stress  has  been 
laid  upon  alcohol  as  an  article  of  diet,  and  the  testimony  seems  to 
support  the  claims  for  its  consideration.  Whisky  may  be  given  in 
the  form  of  milk  punch  every  few  hours.  AYines  are  not,  as  a  rule, 
so  Avell  borne,  and  beer  is  more  prone  to  disturb  the  gastric  and 
other  functions.  Mild  acidulous  drinks  are  usually  demanded,  to  con- 
trol the  generally  persistent  thirst.  The  bowels  should  be  kept  relaxed, 
but  active  purgation  should  be  avoided.  The  old  theory  of  treating 
these  cases  with  cathartics  to  favour  the  elimination  of  the  poison, 
is,  in  the  light  of  the  now  well-understood  pathology,  a  fallacious 
doctrine. 

The  suggestion  has  been  made  that  in  view  of  the  probable  up- 
ward extension  of  the  infection  in  puerperal  fever,  and  of  the  con- 
sequent involvement  of  the  Fallopian  tubes,  a  sound  should  be  passed 
through  the  uterine  cavity  and  the  orifice  of  the  tube  for  the  pur- 
pose of  drainage;  some,  indeed,  have  gone  so  far  as  to  suggest  the 
expediency  of  irrigating  the  Fallopian  tubes.  (See  Infections  of  the 
Fallopian  Tubes.)  A  method  of  this  kind  is  unsurgical  in  the  extreme, 
for  the  reasons,  first,  that  no  surgeon,  however  deft  he  may  be,  can 
be  sure  of  the  distention  of  the  tube;  and,  next,  that  he  can  not  dis- 
tinguish the  orifice  of  the  tube  within  the  uterine  cavity  in  the  post- 
parturient  condition.  The  most  that  he  will  be  likely  to  accomplish  by 
the  procedure  is  to  establish  a  fresh  infection  atrium  within  the  uterus. 

Tuberculosis  of  the  Uterus. — A  description  of  tuberculosis  of  the 
uterus  must  be  divided  into  two  parts,  since  it  is  a  well-established  fact, 


INFECTIONS   OF   THE  UTERUS  385 

according  to  Whitacre,  that  tuberculosis  of  the  body  of  the  uterus  and 
tuberculosis  of  the  cervix  are  quite  independent  of  each  other.  A  lesion 
beginning  in  one  portion  rarely  passes  beyond  the  anatomic  dividing 
line  (the  internal  os),  and  the  pathologic  changes  which  the  tubercle 
bacillus  causes  are  markedly  different  in  the  two  regions. 

Tuberculosis  of  the  Cervix  Uteri. — Tuberculosis  of  the  cervix  is  a 
■condition  which  was  declared  by  Kokitansky  and  Lebert  not  to  exist, 
and  Spaeth  in  1885  collected  only  six  cases.  Since  1886,  however, 
when  Hegar  demonstrated  the  clinical  importance  of  genital  tuber- 
culosis, and  since  the  introduction  of  routine  methods  of  bacterial  and 
microscopic  examination  of  cervical  secretions  and  curettings,  the  num- 
ber of  cases  has  multiplied  rapidly,  and  tuberculosis  of  the  cervix  is 
looked  upon  at  the  present  day  as  a  condition  that  must  enter  into  the 
■diagnosis  of  every  lesion  of  the  cervix. 

The  disease  is  usually  secondary  to  tuberculosis  of  the  Fallopian 
tubes,  peritoneum,  or  vagina,  yet  it  may  be  the  sole  seat  of  tuberculosis 
in  the  genital  tract  of  phthisical  women,  or,  as  in  the  cases  of  Fried- 
lander  and  Pean,  it  may  represent  the  only  seat  of  tuberculosis  in  the 
entire  body.  The  relative  infrequency  of  cervical  tuberculosis  has 
been  explained  by  the  resisting  power  of  the  squamous  epithelium  on 
the  portio  vaginalis,  and  by  a  natural  antibacterial  action  of  the  cervi- 
cal canal,  as  has  been  demonstrated  experimentally  by  Menge.  Pre- 
disposing causes  of  infection  are  undoubtedly  to  be  found  in  irritating 
discharges,  lacerations,  and  erosions.  It  is  difficult  to  explain  the 
immunity  of  the  uterus  to  a  simultaneous  infection  when  the  lesion  is 
clearly  secondary  to  a  tuberculosis  of  the  Fallopian  tubes  or  perito- 
neum. The  monthly  exfoliation  of  the  corporeal  endometrium  prob- 
ably plays  a  definite  role  (Sippel,  Vassmer,  Schottlander).  The  infec- 
tion of  the  cervix  may  take  place  by  an  extension  from  either  the 
higher  or  the  lower  parts  of  the  genital  tract,  by  way  of  the  blood 
stream,  or  by  direct  inoculation  from  without. 

Morbid  Anatomy. — In  describing  the  lesions  of  tuberculosis  of  the 
•cervix  Whitacre  recognises: 

1.  A  miliary  form. 

2.  A  diffuse  tuberculous  infiltration  with  ulceration. 

3.  A  papillary  form. 

Sehlitt  describes  a  fourth  form  in  which  the  lesion  consists  of  an 
.apparently  simple  bacillary  catarrh,  which  is  limited  to  the  epithelium 
and  forms  a  caseous  layer  over  its  surface.  Daurios  has  suggested  a 
fistulous  form,  but  the  occurrence  of  fistula?  must  be  considered  acci- 
dental. 

The  miliary  form  may  be  looked  upon  as  the  first  stage  of  the 
diffuse  tuberculous  form,  and  may  be  described  as  a  catarrhal  inflam- 
mation of  the  cervical  mucosa  with  the  presence  beneath  the  epithelial 
surface,  of  miliary  tubercles  too  small  to  be  seen  by  the  naked  eye.  The 
folds  of  the  arbor  vita;  become  enlarged  and  produce  pronounced  villosi- 
iies  and  secondary  viilosities  with  deep  fissures  between  the  folds.  The 
26 


386 


A  TEXT-BOOK  OF  GYNECOLOGY 


epithelium  over  the  surface  remains  intact,  and  small  masses  of  round 
cells  containing  giant  cells,  and  a  few  tubercle  bacilli,  are  found  in 
the  stroma  which  is  at  the  same  time  the  seat  of  a  small  round-celled 
infiltration.  The  glands  are  not  at  first  involved.  Below  the  mucous 
membrane,  miliary  tubercles  of  larger  size  are  found,  and  even  when  we 
have  to  do  with  a  tuberculous  eruption  which  is  slight,  superficial,  of 
recent  date,  and  has  caused  no  destruction  of  tissue,  we  must  expect  to 
find  the  muscular  layers  infiltrated  by  miliary  tubercles  which  are 
formed  along  the  course  of  the  blood  vessels.  The  condition  may  con- 
tinue as  a  miliary  tuberculosis,  the  most  frequent  form  of  cervical  in- 
volvement, or  the  miliary  tubercles  may  increase  in  size  and  number, 
become  caseous,  and  run  together  to  form  the  lesions  of  the  second  or 
diffuse  form,  where  the  mucous  membrane  is  converted  in  part,  or  in 
its  entirety,  into  an  ulcerating  caseous  mass.  When  this  occurs,  the 
glandular  elements  show  every  degree  of  destruction,  the  tissues  show 
infiltration  and  thickening,  and  the  cervical  canal  becomes  a  worm- 
eaten  cavity  containing  caseous  material  (Matthews).  The  interior  of 
such  a  cavity  is  lined  by  tuberculous  granulations  which  bleed  easily 
and  exude  a  heavy  discharge,  and  the  muscular  tissues  are  infiltrated 
by  discrete  miliary  tubercles.  There  is  a  marked  tendency  to  fibrous 
infiltration,  as  was  first  pointed  out  by  Williams. 

The  papillary  form  of  cervical  tuberculosis,  as  reported  by  Frankel, 
Cornil-Pean,  Franque,  and  Vitrac,  possesses  a  special  interest  from  a 

clinical  point  of  view 
because  of  its  naked- 
eye  resemblance  to 
carcinoma  (Fig.  156). 
It  is  characterized  by 
a  papillary  growth  of 
the  arbor  vitse  which 
pushes  back  the  pave- 
ment epithelium  of 
the  portio  vaginalis 
and  attains  a  consid- 
erable tumour  forma- 
tion. These  tumours 
show  slight  tendency  to  break  down  and  present  the  typical  microscopic 
picture  of  tuberculosis.  Their  naked-eye  appearance  is  not  typically 
tuberculous. 

Sijmpioms  and  Diagnosis. — In  determining  the  s5anptoms  of  tuber- 
culosis of  the  cervix  it  is  difficult  to  separate  them  from  the  symptoms 
of  the  primary  disease,  which  is  often  of  much  greater  importance  than 
the  lesion  in  the  cervix.  A  primary  cervical  lesion  gives  no  pain,  and 
there  is  usually  present  a  muco-purulent  leucorrhoea  which  may  be 
occasionally  tinged  with  blood.  A  phj^sical  examination  of  the  cervix 
will  reveal  one  of  the  conditions  previously  described. 

The  diagnosis  of  tuberculosis  from  simple  cervical  endometritis  on 


Fig.  156 


papillary  form  of  cervical  tuberculosis."- 
Whitacre. 


INFECTIONS  OF   THE  UTERUS 


387 


the  one  hand  and  carcinoma  on  the  other  forms  an  important  feature 
in  the  description  of  tuberculosis  of  the  cervix. 

The  condition  will  be  distinguished  from  simple  cervical  catarrh 
by  the  amount  of  destruction  taking  place  in  the  tuberculous  ulceration, 
by  the  presence  of  caseous  material  in  the  discharge,  and  by  the  demon- 
stration of  the  tubercle  bacillus  in  the  cervical  secretions.  Some  con- 
fusion with  chancroid  has  arisen  in  cases  reported  by  Spaeth  and  Zwei- 
fel.  In  the  ulcerative  and  papillary  form  of  the  disease,  the  possibility 
of  confusion  with  the  much  more  common  condition  of  carcinoma  vaust 
be  constantly  borne  in  mind.  Many  cases  of  tuberculous  cervicitis 
have  been  operated  on  for  carcinoma  and  their  true  nature  only  re- 
vealed on  microscopic  examination  (Cornil,  Frankel,  Kaufmann,  Gog- 
lio,  Vitrac,  Emanuel);  and  it  is  probable  that  many  such  mistakes  pass 
unrecognised  when  the  material  is  not  submitted  to  microscopic  ex- 
amination. The  following  table  has  been  arranged  by  Whitacre  to  aid 
the  diagnosis  between  the  two  conditions: 


Size . . . 
Aspect 


Colour 
Touch . 


Spontaneous  pain 
Sensitiveness. . .  . 
Bleeding 

Discharge 

Progress 


Pathologic  histology. 


Bacteria . 


Tuberculosis. 


Small. 

Papillary  form :  A  muriform 
mass  with  small  vegetations  in 
the  vicinity.  Ulcerative  form : 
Surface  covered  by  caseous 
material  and  mucus.  Border 
a  seed  bed  of  granulations. 

Papillary :  Rose- red,  deeper  col- 
our than  surrounding.  Ul- 
cerative: Bottom  yellow  or  red. 

Papillary :  Surface  knobbed, 
smooth,  polished,  elastic,  no 
induration,  limits  not  clear. 
Ulcerative :  Depression  with- 
out diffuse  induration.  Bor- 
der granular. 

Little  or  none 

Present  

May  be  slight  in  both  papillary 
and  ulcerative  form. 

Papillary :  Mucous.  Ulcera- 
tive :  Often  purulent. 

Papillary:  Extremely  slow.  Ul- 
cerative :  Slow,  yet  may  pro- 
duce extensive  ulceration  and 
fistulas. 

Both  show  typical  miliary  tuber- 
cles and  tubercle  tissue. 

Tubercle  bacilli  found  in  smear 
preparations,  or  by  inoculat- 
ing guinea  pig. 


Epithelioma. 


No  regularity. 

Usually  fungous.  The 
cavity  form  lacks  gran- 
ulations in  the  edges. 
Never  solely  intersti- 
tial. 

Grayish. 


Surface  roughened,  con- 
sistence very  hard.  If 
large  and  fungous,  the 
base  is  very  hard. 


Characteristic. 

Absent. 

Frequent  and  abundant. 

Foetid  and  abundant. 

Progressive  and  accom- 
panied by  constitu- 
tional symptoms. 

Typical  epithelioma  with 
pearls  and  columns  of 
cells. 

None. 


The  treatment  of  tuberculous  disease  of  the  cervix  should  be  radical 
when  tbo  disease  is  primary  and  whenever  it  will  prolong  the  life  or 
contribute  to  the  comfort  of  the  patient,  but  there  are  naturally  many 
cases  associated  with  advanced  tuberculosis  of  the  lungs,  intestines. 


388  A  TEXT-BOOK  OP   GYNECOLOGY 

or  tubes,  in  which  no  operative  measures  would  be  justifiable.  Any 
operation  undertaken  for  the  cure  of  the  condition  must  be  extensive, 
since  Cornil  and  others  have  shown  that,  even  in  recently  developed 
and  apparently  superficial  tuberculosis,  there  is  already  an  extension 
of  miliary  tubercles  along  the  blood  vessels  into  the  deepest  muscle 
layers.  If  the  uterus  can  be  demonstrated  to  be  free  a  high  amputa- 
tion of  the  cervix  should  be  done,  yet  many  authors  insist  upon  hys- 
terectomy as  the  rational  treatment  because  of  the  almost  uniform 
involvement  of  the  tubes,  the  difS.culty  of  getting  beyond  the  tuber- 
culous process,  and  the  fact  that  there  is  no  certain  method  of  deter- 
mining the  presence  of  a  tuberculous  endosalpingitis.  (For  technique 
see  Panhysterectomy  and  Vaginal  Hysterectomy.)  Aron  and  Tillaud 
warn  against  forcible,  mechanical  handling  of  the  cervix,  since  we  may 
thereby  set  up  a  general  tuberculosis.  Palliative  measures  will  consist 
in  the  thorough  curetting  and  cauterizing  of  ulcers,  the  excision  of 
fistulae,  the  treatment  by  iodoform,  and  cleansing  douches. 

Corporeal  Tuberculosis  of  the  Uterus  (Tuberculous  Endometritis). — 
Tuberculosis  of  the  body  of  the  uterus,  or  tuberculous  endometritis, 
must  be  described,  as  has  already  been  stated,  as  a  lesion  distinct  from 
tuberculous  cervicitis,  and  its  frequency,  compared  with  that  of  the 
latter  condition,  will  make  it  a  much  more  important  lesion.  Tubercu- 
losis of  the  uterus  occurs  in  two  thirds  of  all  cases  of  general  tubercu- 
losis; it  occurs  in  connection  with  tuberculous  disease  of  other  genital 
organs,  or  the  process  may  be  primary  in  the  endometrium.  From  the 
point  of  frequency,  the  corporeal  endometrium  stands  second  among 
the  female  genital  organs.  This  type,  like  all  other  forms  of  genital 
tuberculosis,  has  been  studied  more  especially  since  Hegar  called  atten- 
tion to  its  clinical  importance,  yet  the  frequency  of  the  uterine 
disease  has  only  been  fully  appreciated  in  the  last  few  years  since 
routine  histological  and  bacteriological  examinations  of  all  curettings 
have  been  made.  Its  real  frequency  is  certainly  well  shown  by  a  series 
of  six  cases  which  were  observed  by  Vassmer  in  the  very  short  period 
of  ten  months. 

The  uterus  certainly  may  be  infected  by  the  tubercle  bacillus  either 
from  above  or  from  below,  and  its  frequent  association  with  tubal  dis- 
ease would  indicate  that  a  descending  infection  is  the  more  common. 
Coitus  certainly  must  be  considered  to  be  a  source  of  infection  when 
we  remember  the  frequency  of  tuberculous  disease  of  the  male  genito- 
urinary tract,  and  particularly  since  the  demonstration  by  Jani  of 
tubercle  bacilh  in  .the  semen  and  in  the  apparently  healthy  prostate 
and  testicles  of  men  suffering  from  phthisis.  Numerous  cases  are 
reported  where  Avomen  suffering  from  genital  tuberculosis  have  lived 
with  tuberculous  men.  Jani  has  injected  the  apparently  healthy  tes- 
ticle of  tuberculous  men  into  the  peritoneal  cavity  of  guinea  pigs  and 
has  produced  a  typical  tuberculous  peritonitis.  It  has  been  asserted 
that  a  tuberculous  process  arising  from  coitus  is  primarily  a  tubal 
tuberculosis,  and  that  the  uterus  is  secondarily  infected.     Instruments 


INFECTIONS  OF   THE  UTERUS  389 

or  the  examining  finger  may  carry  infection,  or  the  transfer  may  he 
by  direct  self-infection  from  a  tuherculosis  of  the  vulva,  vagina,  or  from 
tuberculous  stools.  The  relative  immunity  of  the  vulva,  vagina,  and 
cervix,  has  been  explained  by  their  protecting  flat  epithelium,  and  in 
the  uterine  cavity  we  find  again  a  decided  protection  in  the  monthly 
exfoliation  of  the  mucous  membrane.  The  puerperal  state  certainly 
predisposes  to  infection,  as  is  shown  by  the  authentic  cases  of  Frorieps, 
Kokitansky,  Heimbs,  Brues,  Geil,  Schiill,  and  by  the  demonstration  of 
tubercle  bacilli  by  Hiinermann  in  a  septic  thrombus  after  abortion. 
Schmorl,  Eockel,  Thorn,  and  others,  have  reported  cases  of  pregnancy 
that  began  and  went  to  full  term  in  spite  of  a  caseous  endometritis. 

The  age  of  the  patient  seems  to  make  little  difference,  yet  Kauf- 
mann  holds  that  the  female  organs  show  a  predisposition  to  tuberculo- 
sis with  the  decline  of  their  activity. 

Mo7-hid  Anatomy. — Pathologically,  tuberculosis  of  the  uterus  is 
divided  by  most  authors  into — 

1.  A  miliary  form  without  ulceration. 

2.  A  chronic  diffuse  or  caseous  endometritis. 

3.  A  chronic  fibroid  type. 

The  second  is  the  clinical  type  with  which  we  are  familiar;  the  first 
is  the  very  earliest  stage  of  the  chronic  diffuse  form  or  a  part  of  a  gen- 
eral eruption  of  tubercles  and  gives  no  symptoms;  while  the  third  has 
been  very  rarely  recognised. 

The  study  of  these  lesions  will  be  much  simplified  by  considering 
them  to  be  different  stages  of  the  same  condition,  and  by  stating  that 
conditions  of  number  and  virulence  of  the  bacteria,  mixed  infection, 
and  the  activity  of  the  reparative  process,  will  determine  the  miliary, 
caseous,  pyometric,  or  fibroid  form. 

The  miliary  form  begins  by  a  deposit  of  minute  tubercles  in  the 
interglandular  substance  of  the  mucous  membrane  of  the  fundus  of 
the  uterus  near  the  entrance  of  the  Fallopian  tubes  (Kelly,  CuUen, 
Williams,  Walther,  Vassmer).  The  epithelial  surface  remains  intact, 
as  does  also  the  glandular  element,  and  the  presence  of  a  few  tubercles 
made  up  of  epithelial  cells  alone,  or  of  .single  giant  cells  containing 
tubercle  bacilli,  may  be  the  only  evidence  of  tuberculosis  in  the  entire 
mucosa.  Later,  the  epithelioid  nodules  are  surrounded  by  small  round 
cells,  and  still  later  giant  cells  appear  in  their  centre  and  only  remnants 
of  the  glands  remain  (Fig.  157).  In  more  advanced  cases,  the  miliary 
tubercles  are  more  numerous,  and  the  glandular  tissue  is  so  much  affected 
that  Cornil  and  Franque  have  characterized  it  as  a  chronic  tuberculous 
endometritis  with  the  principal  participation  of  the  glands,  which  be- 
come enlarged  and  show  indistinct  markings.  Coincident  with  the 
glandular  hypertrophy  there  is  a  strong  infiltration  of  the  interglandu- 
lar tissue  (Abel).  Polyp  formation,  however,  which  is  so  frequent  in 
other  types  of  endometritis,  and  which  forms  a  distinct  class  in  tubercu- 
lous cervicitis,  does  not  occur,  and  nodules  larger  than  a  pea  are  never 
seen.     Madlener  and  Zahn  have  reported  cases  in  which  large  polypi 


390 


A  TEXT-BOOK  OF   GYNECOLOGY 


'-^i^^^h^' 


were  found  to  contain  miliary  tubercles  and  tubercle  bacilli,  but  they 
are  considered  to  be  a  secondary  infection  of  a  pre-existing  polyp. 

The  miliary  tubercles  finally  run  together,  caseate,  and  break  down 
to  form  irregular  undermined  ulcers,  which,  by  their  confluence,  con- 
vert the  endometrium  into  a  caseous  mass  involving,  first,  the  superficial 

layers,  then,  the  entire 
thickness  of  the  mucous 
membrane.  Below  this 
is  a  zone  of  typical  tu- 
berculous tissue  consist- 
ing of  epithelioid  cells, 
tubercles,  giant  cells,  and 
a  varying  amount  of 
gland  remnants.  It  is 
important  to  remember 
that  the  caseous  mass 
simply  replaces  the  mu- 
cosa (Pozzi).  The  mus- 
cle tissue  shows  distinct 
miliary  and  submiliary 
tubercles  which  are 
formed  along  the  course 
of  the  infiltrated  blood 
vessels  (Hofbauer).  The 
muscle  tissue  is  usually 
distinctly  hypertrophied 
and  finally  becomes  extensively  infiltrated  and  destroyed.  A  mixed 
infection  by  the  pyogenic  cocci,  when  associated  with  mechan- 
ical obstruction  of  the  internal  os,  will  lead  to  pyometra — a  very  com- 
mon condition. 

The  chronic  fbroid  type  of  tuberculous  endometritis  was  first  de- 
scribed by  Williams  as  a  miliary  tuberculosis  characterized  by  an  ex- 
cessive development  of  fibrous  tissue  within  and  around  the  miliary 
tubercles.  Thus  far,  it  has  been  recognised  on  the  autopsy  table 
alone. 

The  symptoms  of  the  disease  are  not  characteristic  and  are  prac- 
tically those  of  an  ordinary  endometritis  with  thickening  of  the  uterine 
wall.  Pain,  temperature,  and  a  general  tuberculous  appearance  are 
absent.  There  may  be  a  noncharacteristic,  mucopurulent,  even  case- 
ous, discharge,  but  Vassmer  has  found  no  discharge  in  a  series  of  six 
cases.  Amenorrhcea  was  present  in  the  majority  of  reported  cases, 
excessive  bleeding  very  seldom;  but  menstrual  disturbance  is  prob- 
ably not  important.  Suspicious  points  in  the  history  will  be  the 
chronicity,  the  presence  of  a  general  tuberculosis,  and  tuberculosis  in 
the  husband. 

Diagnosis. — As  has  just  been  stated,  the  symptoms  of  tuberculous 
endometritis  are  not  sufiiciently  characteristic  to  distinguish  it  from 


Fib.  157. — "  Giant  cells  {h)  appear  .  .  .  and  only  i-emnants 
of  the  glands  (a)  remain." — Whitacke  (page  389). 


INFECTIONS  OP   THE  UTERUS  391 

simple  endometritis  or  carcinoma,  and  experience  has  shown  that  the 
diagnosis  can  only  be  made  by  detecting  the  tubercle  bacillus  in  the 
histologic  structure  of  tubercle  tissue  in  scrapings  from  such  a  uterus. 
The  tubercle  bacillus  has  been  found  with  varying  frequency  both  in 
the  secretions  from  the  uterus  and  in  uterine  curettings  (Walther,  Veit, 
Peraire).  In  the  beginning  stages  of  the  disease,  their  scarcity  renders 
a  diagnosis  by  this  means  extremely  difficult,  but  in  the  more  ad- 
vanced forms  the  bacilli  are  numerous.  When  not  found  by  micro- 
scopic examination  in  curettings,  their  presence  may  be  demonstrated 
by  injecting  the  curettings  into  the  peritoneal  cavity  of  the  guinea 
pig.  A  typical  peritoneal  tuberculosis  will  develop  in  from  twelve  days 
to  four  weeks  if  the  bacilli  are  present,  even  in  small  numbers. 

The  histological  diagnosis  is  made  difficult  by  the  fact  that  the 
tubercles  are  not  always  typical,  that  a  simple  infiltration  of  the  stroma 
looks  much  like  tubercle  tissue,  and  that  giant  cells  are  sometimes 
found  in  an  interstitial  endometritis.  The  presence  of  the  epithelioid 
cells  of  tuberculosis  in  the  stroma  of  the  mucous  membrane,  together 
with  the  occasional  distortion  of  the  glands,  may  lead  to  a  confusion 
with  carcinoma. 

Treatment. — The  question  of  the  appropriate  operative  treatment 
for  tuberculous  endometritis  is  as  yet  sub  judice.  Certain  ojDerators 
would  insist  upon  hysterectomy  as  soon  as  the  diagnosis  is  made 
(Schauta,  Pozzi,  Fehling);  while  others  would  recommend  simple 
curetting  and  subsequent  cauterization  with  pure  carbolic,  and  treat- 
ment by  iodoform.  Sippel,  Walther,  Meyer  and  Halbertsma  report 
cases  of  complete  cure  after  curetting,  the  latter  after  five  years.  Sip- 
pel  has  shown  the  healing  influence  of  continued  menstruation  on  dis- 
ease processes  in  the  mucosa — a  fact  which  must  not  be  disregarded. 

It  must  be  remembered,  however,  that  tuberculosis  of  the  uterus  is 
generally  secondary  to  tubal  tuberculosis,  and  in  the  presence  of 
advanced  disease  demanding  removal  of  these  organs  there  could  be 
slight  reason  for  preserving  the  uterus.  The  association  of  a  unilateral 
tubal  tuberculosis  will  call  for  a  laparotomy  for  the  removal  of  the 
tube,  and  a  thorough  curettement  of  the  uterus.  It  must  be  remem- 
bered in  removing  tuberculous  appendages,  that  a  tuberculous  endome- 
tritis probably  already  exists,  and  that  the  uterus  should  be  curetted 
if  left  behind.  Kelly  has  found  a  tuberculous  involvement  in  such 
cases  when  it  was  entirely  unsuspected.  It  is  well  to  remember  that 
these  cases  should  not  be  considered  malignant,  and  that  conservative 
measures  are  indicated  in  selected  cases. 

Syphilis  of  the  uterus  was  formerly  supposed  to  be  of  relatively 
frequent  occurrence.  This  was  due  to  the  fact  that,  before  the  days 
of  Emmet,  the  granular  surface  of  a  cervical  ectropion  was  frequently 
mistaken  for  a  true  ulcer — -often  syphilitic  in  character.  Since  lacera- 
tion of  the  cervix  has  become  a  recognised  condition,  it  is  discovered 
that  what  was  formerly  looked  upon  as  ulceration,  is,  as  already 
stated,   nothing  more   or  less  than  the   everted   mucous   membrane, 


392  ^  TEXT-BOOK  OF   GYNECOLOGY 

studded  with  hypertrophied  follicles.  Syphilis  may  occur  as  either  a 
primary  or  a  secondary  affection  of  the  uterus. 

Chancre  of  the  cervix  was  recognised  in  1838  by  Ricord,  who  found 
it  in  13  out  of  199  cases,  or,  practically  in  6  per  cent  of  women 
presenting  themselves  at  his  clinic  with  primary  syphilitic  sores. 
Schwartz  found  it  in  93  out  of  686  collated  cases.  Chancre  of  the 
cervix  is  of  about  the  same  frequency  of  occurrence  as  primary  chancre 
of  the  vagina.  This  statement  is  based  upon  tables  compiled  by 
Gliick  {Wiener  medicinische  Presse,  1881),  by  which  it  appears  that 
primary  infection  of  the  vagina  occurs  in  from  0.87  per  cent  to  -|-  6 
per  cent  of  all  cases  of  primary  syphilis  in  women.  Chancre  of  the 
cervix  is  generally  single,  although  it  may  be  multiple.  It  may 
coexist  with  chancre  in  some  other  part  of  the  genitalia.  Fournier 
{Annales  de  gynecologie,  1876)  reported  a  case  in  which  three  chancres 
of  the  cervix  coexisted  with  one  involving  the  fourchette.  Whitehead 
{Abortion  and  Sterility)  reported  a  case  of  syphilitic  ulcer  of  the  cer- 
vix, associated  with  constitutional  symptoms,  while  a  similar  case  was 
recorded  as  long  ago  as  1859  {British  Medical  Journal)  by  Parker. 
.  Herman  {Obstetrical  Transactions,  London,  1885)  recorded  a  case  of 
large  chancre  of  the  cervix,  associated  with  distinct  secondary  symp- 
toms. Mackenzie  {British  Medical  Journal,  1854)  called  attention  to 
the  fact  that  important  pathologic  changes  in  the  uterus  occur  as 
the  secondary  results  of  syphilis.     Parker  confirmed  this  view. 

The  symptoms  of  jDrimary  infection  of  the  uterus  consist  of  an 
ichorous  discharge,  associated  with  more  or  less  general  pelvic  discom- 
fort. This  circumstance  generally  leads  to  an  examination  when  an 
ulcer  not  self-inoculable  and  presenting  the  characteristic  physical 
features  of  a  chancre,  is  revealed.  These  ulcers  may  vary  in  size  from 
a  minute  disk  to  the  size  of  a  shilling.  In  Herman's  case  the  ulcer 
was  of  the  latter  size  and  presented  the  appearance  of  a  grayish- 
yellow  slough,  surrounded  by  an  inflamed  areola.  The  edges  were 
sharp,  discrete,  and  indurated.  If  of  long  standing,  it  may  be  asso- 
ciated with  syphilides  of  the  vaginal  mucosa  and  the  pudendal  integu- 
ment. 

In  chancre  of  the  cervix  the  inguinal  lymphatics  are  not  involved, 
unless  the  condition  coexists  with  a  primary  sore  of  the  external 
genitalia.  Intrapelvic  lymphangeitis  and  lymphadenitis  are,  however, 
frequent  concomitants.  The  lymphatic  vessels  can  be  felt  like  tender 
and  tense  cords  above  either  fornix  of  the  vagina;  while  the  enlarged 
glands  may  be  felt  as  distinct  nodules  in  the  superimposed  cellular 
structure.  Infection  of  the  intrapelvic  lymphatics  may  result  in  sup- 
puration of  the  glands — a  condition  which  may,  with  propriety,  be 
designated  as  an  internal  bubo. 

Secondary  syphilis  of  the  uterus  is  generally  associated  with  a  puru- 
lent discharge  and  with  enlargement  and  tenderness  of  the  portio 
vaginalis.  Patches  of  redness,  sometimes  of  a  very  dark  colour,  are 
frequently  noticed  on  the  cervix.     In  the  centre  of  certain  of  these 


INFECTIONS   OP  THE   UTERUS  393 

reddened  areas,  ulcerative  tendencies  are  occasionally  manifested.  Care- 
ful examination  will  generally  reveal  slight  deposits  of  cicatricial  tissue 
on  the  cervix.  Ulcers  varying  in  size  and  appearance  are  occasionally 
found. 

Endometritis  is  a  common  accompaniment  of  these  changes.  It  is 
to  this  condition  that  the  tendency  of  syphilitic  women  to  miscarry, 
is  attributed. 

Careful  bimanual  exploration  will  generally  reveal  more  or  less 
hypertrophy  of  the  entire  uterus.  Parker  considers  these  symptoms 
indicative  of  syphilis,  because,  according  to  his  observation,  they  are 
found  in  about  60  per  cent  of  the  cases  of  confirmed  lues;  while  they 
are  not  foimd  with  anything  like  equal  frequency  in  women  in  whom 
a  syphilitic  history  can  not  be  otherwise  established. 

The  diagnosis  of  chancre  of  the  uterus  can  generally  be  made  by 
careful  study  of  the  physical  conditions  presented.  The  promptness 
with  which  the  lesion  yields  to  antisyphilitic  treatment,  will  dispel 
any  remaining  doubts  as  to  the  character  of  the  trouble.  Secondary 
syphilis  of  the  uterus,  however,  may  readily  be  confused  with  hyper- 
plasia due  to  other  infectious  causes. 

A  careful  study  must,  therefore,  be  made,  not  only  of  the  previous 
clinical  history,  but  of  the  bacteriological  features  of  the  case. 

Treatment. — The  treatment  of  these  cases  may  be  summarized  as 
antisyphilitic.  Chancre  of  the  cervix  should  be  cauterized,  with 
either  nitric  acid,  or  the  pure  nitrate  of  silver.  After  the  slough 
separates,  the  ulcer  should  be  treated  with  iodoform,  the  vagina  being 
kept  packed  with  iodoform  gauze.  The  parts  should  be  carefully  irri- 
gated, between  dressings,  with  a  l-to-2,000  solution  of  bichloride  of 
mercury.  Constitutional  treatment  should  consist  of  the  administra- 
tion of  mercury,  either  in  combination  or  alternating  with  the  iodides. 
The  more  profound  organic  changes  of  the  uterus  may  require  atten- 
tion. Forcible  dilatation  of  the  cervix  and  vigorous  curettage  of  the 
endometrium  are  the  only  means  by  which  hypertrophy  of  the  latter 
structure  may  be  overcome. 

Echinococcous  infection  of  the  uterus,  while  not  of  common  oc- 
currence, probably  exists  with  greater  frequency  than  is  indicated  by 
the  records.  The  demonstration  of  booklets  in  many  so-called 
"  hydatid  moles  "  of  the  uterus  is  an  indication  of  parasitic  origin 
of,  at  least,  an  important  number  of  these  cases.  It  would  seem  as 
if  a  more  careful  investigation  of  these  intrauterine  products  would 
tend  to  eliminate  pregnancy  as  an  essential  element  in  their  produc- 
tion, and  to  restrict  their  etiology  within  the  category  of  infections. 
That  echinococci  may,  however,  attack  the  decidual  structures  of  a 
recent  pregnancy,  is  beyond  doubt.  These  organisms  may  also  invade 
the  muscularis  of  the  uterus.  When  the  parenchyma  is  the  primary 
lo€i/s  of  infoctiou,  the  resulting  parent  cyst  may  develop,  as  does  a 
myoma,  cither  beneath  the  mucous  membrane,  or  beneath  the  perito- 
neum. One  of  the  earliest  cases  on  record — i.  e.,  MacNeven's  (New  Yorh 


394  A  TEXT-BOOK  OF   GYNECOLOGY 

Journal  of  Medicine,  1849) — was  an  example  of  submucous  develop- 
ment,, while  a  more  recent  case  by  Altormyan  {Lancet,  April  4,  1891)  is  a 
distinct  example  of  subperitoneal  development  of  the  cyst.  The  same 
may  be  said  of  the  case  reported  by  Freiind  and  Chadwick  {American 
Journal  of  Obstetrics,  1874-'75). 

The  symptoms  of  echinococcous  infection  of  the  uterus  are  not 
essentially  pathognomonic.  There  is  tumefaction  in  the  uterine  region; 
a  sense  of  weight,  that  may  run  through  several  months  or  years;  ces- 
sation or  irregularity  of  menstruation;  increasing  pressure  on  the 
bladder  and  bowels;  while  there  usually  occurs  a  progressive  decline 
of  general  health.  The  tumefaction,  which  is  ordinarily  median  at 
its  commencement,  may  develop  either  to  one  side  or  the  other,  accord- 
ing as  the  tumour  grows  either  to  the  right  or  to  the  left.  The 
tumour,  itself,  in  a  case  of  parenchymatous  infection,  is  generally 
described  as  smooth  and  elastic.  When  it  presents  in  the  uterine 
cavity  or  at  the  cervical  margin,  it  is  generally  fluctuating  at  the 
presenting  point,  although  the  palpation  wave  is  transmitted  but  in- 
distinctly to  remoter  parts  of  the  growth.  In  the  uterine  cavity,  the 
cyst  may  present  many  features  in  common  with  the  amniotic  sac  for 
which  it  has  been  mistaken.  In  cases  of  echinococcous  infection  of  the 
uterine  cavity,  the  symjjtoms  may  be  essentially  those  of  pregnancy. 
The  uterus  becomes  enlarged  and  softened,  the  cervix  presenting  a 
bluish  aspect.  The  womb  enlarges,  progressively  and  symmetrically, 
the  breasts  enlarge  and  may  contain  milk,  while  there  are  not  infre- 
quent reflex  disturbances  of  the  stomach.  It  is  the  occurrence  of  these 
symptoms  which  has  generally  caused  infections  of  the  uterine  cavity 
by  the  echinococcus,  to  be  looked  upon  as  pregnancy,  and  the  result- 
ing cysts  to  be  designated  as  degenerated  ova.  In  practically  all 
these  cases,  however,  the  usual  amenorrhoea  of  pregnancy  is  absent, 
while  the  patient  complains  of  more  or  less  constant  dribbling  of  blood 
from  the  uterus.  AMiile  this  is  true,  the  fact  must  be  recognised  that 
infection  of  the  uterine  cavity  by  the  echinococcus  may  coexist  with 
pregnancy,  as  was  true  in  MacNeven's  case,  in  which  a  large  echino- 
coccus cyst  was  expelled,  intact,  during  a  true  labour  and  immediately 
preceding  the  rupture  of  the  amniotic  sac.  The  exact  diagnosis  can 
not  be  made  without  the  demonstration  of  the  booklets.  Echinococcous 
infection  of  the  uterus  may  occur  at  any  age.  Szancer  {Zeitschrift  fiir 
Gehurtshiilfe  und  Gyndkologie,  1879)  reports  a  case  occurring  in  a 
girl  of  twelve,  while  Hislop  reports  one  aged  seventeen,  and  it  has 
been  found  in  patients  of  more  advanced  years. 

Invasion  of  the  uterus  seems  to  be  eifected  through  any  abrasion 
in  the  mucous  surface,  although,  in  a  number  of  cases,  the  infection 
of  the  uterus  has  been  secondary  to  the  invasion  of  remoter  organs, 
notably  the  liver.  Microscopicall)'-,  the  cysts  consist  of  structureless 
stratified  membranes,  containing  scoleces  and  separate  echinococcic 
booklets.  The  cysts,  themselves,  multiply  by  endogenous  prolifera- 
tion, the  resulting  mass  consisting  of  a  large  mother  cyst  containing 


INFECTIONS  OF  THE  UTERUS  395 

numerous  daughter  cysts,  varying  in  size  from  a  millet  seed  to  a  pea, 
or  even  larger.  Each  cyst  contains  clear,  limpid  fluid,  containing 
no  sediment,  but  yielding  traces  of  albumin.  When  evacuated  by 
incision,  the  mother  cyst  does  not  collapse  readily,  showing  the  exist- 
ence, not  only  of  structural  development,  but  of  extensive  peripheral 
infiltration. 

Evidence  seems  to  point  to  the  lymphatics  as  the  chief  avenue 
for  the  migration  of  these  infectious  elements,  particularly  when  con- 
sidered with  reference  to  their  secondary  manifestation.  These  para- 
sites have,  however,  the  ability  to  penetrate  the  normal  matrix;  even 
after  evacuation  of  the  parent  cyst,  progressive  invasion  of  the  tissues 
may  occur,  until  the  peritoneum,  the  bladder,  or  even  the  intestine, 
is  penetrated. 

Treatment. — This  consists  in  the  evacuation  of  the  cyst  whenever 
accessible.  The  cyst  cavity  should  be  opened  freely,  its  walls  should 
be  curetted  vigorously,  after  which  it  should  be  irrigated,  first  with 
25-per-cent  solution  of  hydrogen  peroxide,  and  subsequently  packed 
with  iodoform  gauze.  Drainage  should  be  maintained  until  the  cav- 
ity is  thoroughly  collapsed.  If,  however,  the  disease  shows  a  tend- 
ency to  progressive  invasion  of  neighbouring  structures,  hysterectomy 
should  be  performed.  When  the  infection  is  restricted  to  the  uterine 
cavity,  the  expulsion  of  the  cystic  product  generally  results  in  the 
immediate  recovery  of  the  patient. 


CHAPTEE  XXVIII 

NEOPLASMS   OF   THE   UTERUS 

Neoplasms  of  the  uterus  in  general ;  varieties — Benign  neoplasms — Fibromyomata : 
Causes,  pathology,  histology,  secondary  degenerations,  diagnosis — Complicat- 
ing pregnancy — Treatment :  Medicinal  and  electrical ;  surgical,  terms  employed 
— Indications — Myomectomy — Supravaginal  hysterectomy  ;  extra-peritoneal 
treatment  of  the  pedicle — Panhysterectomy ;  Reed's  operation ;  vaginal  hyster- 
ectomy— Vaginal  myomotomy — Extirpation  of  polypi. 

Neoplasms  of  the  Uterus  in  General. — There  is,  perhaps,  no  organ 
of  the  body,  in  either  tlie  male  or  the  female,  which  is  so  often  the 
seat  of  tumour  formation  as  the  uteriis.  The  intrinsic  causes  of 
neoplastic  diseases  of  the  womb  are  usually  as  obscure  as  of  those 
of  any  part  of  the  body.  Embryonic  inclusions,  nutritive  disturbances, 
irritation,  and  heredity,  play  a  certain  role  as  predisposing  causes,  yet 
their  relation  to  tumour  formation  is  by  no  means  always  demonstrable. 
Neoplasms  of  the  uterus  may  be  considered  in  relation  to  the  dilfer- 
ent  parts  of  the  organ  from  which  they  arise.  They  may  be  divided 
according  to  their  main  clinical  features  into  benign  and  malignant, 
or,  according  to  their  histology,  into  connective  tissue  and  epithelial 
new  growth.  The  connective-tissue  tumours  occurring  in  the  uterus 
are  the  fihromyoma,  the  sarcoma,  the  endothelioma,  and  some  mixed 
tumours  of  minor  importance.  The  epithelial  neoplasms  comprise  the 
adenoma  malignum,  the  carcinoma,  and  the  syncytioma  malignum. 

Benign  Neoplasms  of  the  Uteeus  ^ 

The  tumours  variously  designated  as  fibroma,  fibromyoma,  fibroid 

or  myoma  of  the  uterus,  are  the  most  common  neoplasms  that  develop 
in  that  organ.  They  are  derived  from  the  muscular  coat  and  are  com- 
posed of  involuntary  muscle  cells  and  ordinary  fibrous  connective  tis- 
sue, mixed  in  varying  proportions. 

Their  causes  are  various.  The  time  of  life  when  fibromyomata 
usually  occur  is  that  of  sexual  activity,  but  there  have  been  reported 
a  number  of  cases  of  this  kind  in  children  and  in  women  after  the 
climacterium.  A  good  deal  has  been  written  upon  the  subject  of 
the  influence  of  prolonged  virginity  and  abstinence  from  sexual  inter- 
course, married  life,  abnormal  sexual  irritation,  sexual  excesses,  mas- 
turbation, and  so  forth,  upon  the  development  of  fibromyoma.  Hered- 
396 


NEOPLASMS  OF  THE  UTERUS  397 

ity  has  likewise  been  considered  as  a  factor  in  the  production  of 
these  neoplasms.  Kace  has  been  cited  as  a  predisposing  cause.  It 
is  well  know^n  that  many  American  writers  hold  that  myomata  are 
much  more  common  in  the  negro  than  in  the  Caucasian  races.  The 
statistics,  the  views  and  the  theories  of  various  experienced  authors, 
are,  however,  so  contradictory  in  many  points,  that  we  can  not  draw 
any  definite  general  conclusions,  and  must  for  the  time  being  leave 
open  many  questions  as  to  the  etiology  of  true  fibromyoma. 

There  is  one  class  of  fibromyomata,  recently  fully  described  in  a 
classical  monograph  by  von  Recklinghausen,  the  adenomyomata,  which 
in  their  origin  clearly  stand  in  a  causal  nexus  with  certain  embryonic 
inclusions  in  the  uterus. 

Yeit,  in  an  article  on  the  etiology  and  symptomatology  of  fibro- 
myoma, comes  to  the  following  conclusions:  "  So  far  as  the  common 
myomata  (excluding  the  adenomyoma)  are  concerned,  I  hold  that 
their  origin  from  an  embryonic  inclusion  ('  anlage ')  has  not  been 
proved.  It  appears,  however,  that  heredity  plays  a  role  therein,  and 
one  is  also  able  to  understand  that  irritation,  acting  chronically 
upon  the  uterus,  may  give  rise  to  the  formation  of  myomata;  the 
modus  operandi  of  the  latter^  however,  is  not  yet  clearly  proved." 

Pathology  of  Fibromyoma  Uteri. — Fibromyomata  may  arise  from  the 
museularis  of  the  body  as  well  as  from  that  of  the  cervix.  They  vary 
a  good  deal  in  size  and  shape,  and  their  particular  position  has  a  good 
deal  of  influence  in  this  respect.  They  may  be  single,  but  more  fre- 
quently they  are  multiple.  One  not  infrequently  finds  in  uteri  re- 
moved for  some  cause,  or  obtained  from  the  post-mortem  table,  very 
small  myomata  which  have  not  given  rise  to  any  symptoms.  On  the 
other  hand  these  tumours  may  attain  an  enormous  size.  Stockard 
saw  in  a  coloured  woman  a  myoma  weighing  135  pounds,  and  Hunter  re- 
ports the  finding  post  mortem  of  a  myoma  weighing  140  pounds,  while 
the  rest  of  the  body  weighed  95  pounds.  According  to  their  seat  and 
mode  of  origin,  myomata  are  divided  into  submucous,  interstitial,  and 
subserous. 

Submucous  myomata  have  their  seat  under  the  mucous  membrane. 
They  may  be  attached  by  a  broad  base  to  the  museularis  or  they 
may,  and  this  is  more  commonly  the  case,  become  pedunculated  and 
project  polyplike  into  the  uterine  cavity.  These  myomata  are  gen- 
erally rich  in  blood  vessels  and  muscle  fibres  and  comparatively  soft. 
They  usually  grow  rapidly  but  rarely  attain  a  very  large  size  If  by 
their  growth  they  are  forced  down  into  the  cervical  canal  they  some- 
times assume  an  hourglass  or  dumb-bell  shape.  They  have  a  marked 
tendency  to  undergo  degenerative  changes  and  to  slough.  The  de- 
scent of  these  submucous  myomata  is  often  due  less  to  their  own 
neoplastic  growth  than  to  oedematous  swelling  in  consequence  of 
circulatory  disturbances  and  to  contractions  of  the  uterus.  These 
muscular  contractions  of  the  womb  may  sometimes  bring  about  the 
spontaneous  separation  and  delivery  of  a  submucous  myoma. 


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Interstitial  fihromyomata  develop  in  the  middle  stratum  of  the  m^us- 
cularis  uteri.  They  are,  as  a  rule,  well  encapsulated,  and  can  there- 
fore be  easily  enucleated.  Only  rarely  is  this  variety  intimately  blended 
and  connected  by  interlacing  bundles  of  muscle  fibres  with  the  sur- 
rounding parts.  If  such  interstitial  tumours  grow  very  large  they  may 
so  stretch  the  parts  of  the  uterus  below  that  these  form  a  kind  of 
peduncle  for  the  tumour.  Such  peduncles  may  in  rare  cases  undergo 
torsion. 

The  subserous  fhromyomata  are  developed  from  the  most  super- 
ficial layers  of  the  muscularis  and  project  from  the  peritoneal  sur- 
face. They  are  connected  with  the  uterus  by  a  more  or  less  con- 
stricted short  j)eduncle  (Fig.  158).     Smaller  subserous  myomata  may 

also  have  a  broad  base, 
but  the  larger  ones  are 
generally  pedunculated. 
The  peritoneum  firmly 
overlies  the  tumour  and 
is  intimately  blended 
with  it  so  that  it  can 
not  easily  be  peeled  off. 
These  tvunours,  in  con- 
quence  of  their  usual 
mode  of  attachment  to 
the  uterus,  are  generally 
more  or  less  movable. 
The  peduncle  may  un- 
dergo torsion  or  kinking. 
Subserous  myomata  are 
very  liable  to  form  adhe- 
sions with  the  neighbour- 
ing sexual  organs,  with 
the  intestines,  and  with 
other  structures.  Myo- 
mata of  this  variety, 
springing  from  the  lateral  margins  of  the  uterus,  often  grow  into  the 
broad  ligament,  separate  its  layers,  and  give  rise  to  what  is  known  as 
intraligamentous  fihromyomata. 

Histology  of  Fihromyomata. — Histologically,  the  fihromyomata  of 
the  uterus  consist  of  the  same  tissues  as  compose  the  muscularis  of 
the  uterus,  namely,  involuntary,  smooth  muscle  fibres,  and  fibrous  con- 
nective tissue.  These  two  kinds  of  tissues  are  present  in  varying  pro- 
portions. Some  tumours  may  contain  only  a  small  amount  of  fibrous 
connective  tissue,  while  in  others  it  may  so  predominate  that  an  almost 
pure  fibroma  exists.  The  muscle  cells  are  arranged  in  bundles  which 
cross  each  other  and  interlace  with  a  great  deal  of  variety  and  irregu- 
larity. Yellow  elastic  fibres  are  Hkewise  found,  also  those  particular 
cells  known  as  "mast  cells"  and  "plasma-mast  cells." 


Fig.  158. — "  They  are  connected  with  the  uterus  by  a 
more  or  less  constricted  short  peduncle." — Herzog. 


NEOPLASMS  OF  THE  UTERUS 


399 


A  particular  variety  of  myoma  is  the  adenomyoma.  These  tumours 
are  ordinarily  of  moderate  size,  and  are  generally  found  near  the  serous 
surface  in  the  posterior  uterine  wall  and  near  the  tubal  angles.  They 
are  not  encapsulated  but  shade  off  diffusely  into  the  surrounding  tis- 
sues and  contain,  besides  the  usual  tissue  elements  of  fibromyoma, 
epithelial  structures.  These  latter  are  of  a  peculiar  glandular  type. 
There  are  generally  seen  a  number  of  smaller  ducts  which  communi- 
cate, like  the  teeth  of  a  comb,  with  a  larger  duct.  These  epithelial 
structures  are  derivatives  of  remnants  of  the  Wolffian  duct  and 
of  the  "  urniere  "  of  the  Wolffian  body,  which  have  been  displaced 
in  development,  and  which,  as  embryonic  inclusions,  give  rise  to 
the  appearance  of  these 
peculiar  new  growths. 
The  latter,  from  a  histo- 
logical standpoint,  must 
be  looked  upon  as  a  mix- 
ture of  connective  tis- 
sue and  epithelial  neo- 
plasms. 

Fibromyomata  often 
bring  about  changes  in 
the  whole  uterus.  The 
muscular  coat,  particu- 
larly if  the  myoma  is  so 
situated  that  it  causes 
uterine  contractions,  is 
liable  to  undergo  some 
hypertrophy  character- 
ized by  an  increase  in 
size  of  the  individual 
muscle  cells.  The  uter- 
ine mucous  membrane 
shows  either  a  glandular 
or  an  interstitial  hyper- 
trophy. Herzog  has  also 
frequently  observed  an 
extensive  oedematous  in- 
filtration of  the  mucosa, 
with  or  without  capil- 
lary interstitial  hemor- 
rhages. Tubes  and  ova- 
ries are  likewise  affected 

when  large  myomata  are  present  in  the  uterus.  Endosalpingitis,  sal- 
pingitis interstitialis,  and  oophoritis  interstitialis  with  condensation  of 
the  ovarian  stroma  and  round-cell  infiltration,  have  been  described. 

Secondary  Degenerations  of  Myomata.— The  secondary  degenerations 
occurring  in  myomata  are  quite  numerous.    Atrophy  sometimes  occurs 


Fig.  159.—"  A  shell  composed  of  lime  salts." — Hekzog 
(page  400). 


400 


A  TEXT-BOOK  OF  GYNECOLOGY 


after  pregnancy  and  after  the  menopause  has  heen  established,  and 
under  other  conditions.  Calcareous  degeneration  is  common,  and  small 
particles  of  carbonates  and  phosphates  of  lime  are  very  frequently  found 
in  myomata.  Or  there  may  be  formed  a  solid  stone  or  a  shell  com- 
posed of  lime  salts.  Herzog  examined  a  case  of  the  latter  kind. 
The  specimen  was  obtained  by  an  operation  performed  by  Dr.  M.  L. 
Harris,  on  a  woman  seventy  years  old.  It  formed  an  elliptical  mass 
about  14  centimetres  long,  consisting  of  a  shell  several  millimetres 
thick,  composed  of  lime  salts  (Fig.  159).  Eeed  removed  from  an 
aged  patient  a  large  interstitial  fibroid  of  lateral  development  which 
had  distended  the  broad  ligament  carrying  the  ovary  and  Fallopian 
tube  of  that  side  nearly  to  the  umbilicus  (Fig.  160).  On  opening  the 
tumour  a  shell  of  calcareous  matter  and  several  foci   of  calcareous 


Fig.  160  (Eeed).—"  Eeed  removed  from  an  aged  patient  a  large  interstitial  fibroid  of  lateral 
development  which  had  distended  the  broad  ligament,  carrying  the  ovary  and  Fallopian 
tube  of  that  side  nearly  to  the  umbilicus." — Herzog. 


degeneration  were  found  (Fig.  161).  Fatty  degeneration  is  also  fre- 
quently seen;  it  often  leads  to  the  formation  of  cystic  spaces  in  the 
tumour.  Myxomatous  degeneration,  inflammation,  necrosis,  and  slough- 
ing, are  observed  in  fibromyomata.    Amyloid  degeneration  has  been  once 


NEOPLASMS  OF   THE   UTERUS 


401 


described  by  Stratz.  Of  malignant  clianges  in  a  primarily  benign  myoma, 
the  sarcomatous  degeneration  is  the  one  most  frequently  met  with. 
Von  Eecklinghausen  has  seen  several  cases  of  carcinoma  developing  m 


Fig.  161  (Eeed).— "  On  opening  the  tumour  a  shell  of  calcareous  matter  and  several  foci  of 
calcareous  degeneration  were  found." — Heezog  (page  400). 

adenomyomata.  The  other  mixed  tumours,  myochondroma  and  myo- 
osteoma,  have  been  described,  as  well  as  rhabdomyoma  of  a  sarcoma- 
tous type. 

Diagnosis. — These  tumours  are  common  in  women  of  all  races  and 
of  all  ages,  though  more  frequent  in  negroes  and  in  women  between 
the  ages  of  thirty  and  forty  years.  Although  found  prior  to  puberty 
in  rare  instances,  these  growths  are  essentially  incident  to  the  men- 
strual period  of  life.  Unmarried  and  sterile  women  are  especially  prone 
to  this  disease. 

Hemorrhage,  while  not  invariably  present,  is  a  common  and  con- 
spicuous symptom  of  uterine  fibromata.  Profuse  and  prolonged  men- 
struation is  a  marked  and  characteristic  symptom.  It  is  not  uncom- 
mon to  observe  the  most  profound  anaemia  in  consequence,  the  patient's 
skin  assuming  a  waxy,  yellowish  hue,  with  anaemic  heart  murmur  and 
profound  general  exhaustion. 

Pain  is  a  cons])icuous  symptom  in  the  majority  of  cases,  and  is 

the  result  either  of  pressure  or  of  associated  inflammatory  disease  of 

the  Fallopian  tubes  and  ovaries.     The  pain  of  pressure  is  determined 

more  by  the  site  of  the  tumour  than  its  size.     Thus,  when  growing 

27 


402  A  TEXT-BOOK  OF  GYNECOLOGY 

from  the  lower  uterine  segment  and  packing  the  pelvic  cavity,  the 
pressure  on  bowel,  bladder,  and  nerve  trunks,  will  be  more  severe  than 
when  the  tumour  is  situated  higher  and  rises  freely  above  the  brim 
of  the  pelvis.  The  ovaries  and  tubes  are  often  found  in  a  mass  of 
infiammator}^  adhesions,  and  hydrosalpinx  and  pyosalpinx  are  not 
uncommon  accompaniments  of  these  tumours.  Such  comj)lications  may 
render  small  fibroid  tumours  painful  in  the  extreme.  Irritability  of 
the  bladder,  and  obstipation  resulting  from  pressure  of  the  growth,  are 
common  symptoms. 

The  diagnosis  of  uterine  fibromata  is  determined  by  recognising 
these  symptoms  in  conjunction  with  careful  i^hysical  examination  of 
the  j)elvic  organs.  The  bimanual  touch  will  disclose  the  presence  of 
a  tumour,  usually  irregular  in  outline,  and  attached  to  the  uterus.  If 
the  tumour  is  large,  its  firm  consistence  and  nodular  character  may 
be  detected  by  palpation  through  the  abdominal  parietes.  Interstitial 
fibromata  of  S3mimetrical  development  may  be  mistaken  for  pregnancy 
(Fig.  162),  an  error  more  easily  made  from  the  fact  that  pregnancy 


Fig.  162. — "Interstitial  fibromata  of  symmetrical  development  may  be  mistaken  for  preg- 
nancy."— McMuETEY. 

not  infrequently  coexists  with  these  tumours.  The  soft  fibroma,  espe- 
cially if  oedematous,  is  distinguished  with  difficulty  from  an  ovarian 
cystoma;  and  when  cystic  degeneration  has  taken  place  in  the  fibroma, 
diagnosis  is  impossible.  Diagnosis  is  also  practically  impossible  be- 
tween polycystic  ovarian  cystoma  with  general  adhesions,  and  sym- 
metrical uterine  fibroma.  The  clinical  importance  of  these  difficulties, 
however,  is  offset  by  the  practical  fact  that  both  classes  of  tumours 
should  receive  the  same  treatment,  viz.:  removal  by  abdominal  sec- 
tion. The  vaginal  portion  of  the  cervix  is  rarely  involved  by  fibroid 
changes  in  the  uterus  (Fig.  163).    A  small  fibroid  in  the  posterior  uter- 


NEOPLASMS  OF  THE  UTERUS 


403 


Fig.  1 63. — "  Tlie  vaginal  portion  of  the  cervix  is  rarely 
involved  by  fibroid  changes  in  the  uterus." — McMub- 
TEY  (page  402). 


ine  wall  may  be  mistaken  for  retroflexion  of  the  uterus;  and  such  a 
tumour  springing  from  the  supravaginal  cervix  may  be  interpreted  by 
the  touch  as  inflammatory  exudate.  Such  errors  can  be  avoided  only 
by  careful  study  of  the  symptoms  and  history  of  individual  cases,  with 
painstaking  bimanual  examination  after  the  bladder  and  bowel  have 
been  thoroughly  emp- 
tied. Instrumentation 
per  vaginam  and  digital 
exploration  per  rectum 
will  rarely  afford  any 
special  advantage  over 
these  established  means 
of  diagnosis,  and  unless 
done  with  skill  and  with- 
out force,  will  inflict 
pain  and  prove  harmful. 

Pregnancy  as  a  com- 
plication of  uterine  myo- 
mata  occurs  with  suf- 
ficient frequency  to  de- 
serve special  considera- 
tion.    It  is  a  matter  of 

great  practical  importance  to  determine  whether  the  life  of  the  mother 
is  endangered  and  operation  consequently  imperative;  or,  whether 
pregnancy  and  parturition  may  be  safely  completed  without  surgical 
intervention.  While  it  is  exceptional  for  a  woman  with  large  uterine 
myoma  to  become  pregnant,  numerous  cases  are  recorded  where  the 
uterus  has  proved  equal  to  the  demand  and  carried  the  child  to  safe 
delivery  near  to  or  quite  at  full  term.  Under  the  stimulus  of  preg- 
nancy, with  its  increased  blood  supply,  fibroid  tumours  grow  rapidly; 
and  small  tumours  hitherto  unnoticed  may  become  conspicuous.  It 
is  also  true  that,  after  delivery,  fibromata  participate  in  the  retrograde 
changes  in  the  uterus  and  shrivel  to  insignificant  proportions. 

In  certain  exceptional  cases,  where  the  tumour  arises  from  the  lower 
segment  of  the  uterus  and  fills  the  lower  pelvis,  thereby  obstructing 
the  passage  of  the  child,  the  vital  question  of  operative  intervention 
must  be  met  and  determined.  A  case  of  obstructive  myoma  in 
which  a  successful  operation  was  done  by  McMurtry  is  illustrated  in 
Fig.  164  {New  York  Medical  Journal).  Similar  cases  have  been  re- 
ported by  Price,  Hanks,  Eeed,  Vander  Veer,  Ross,  and  others.  This 
question  should  receive  the  most  conservative  consideration,  for,  in 
many  instances,  the  uterus  will  bear  its  additional  burden,  and  if  the 
tumour  is  above  the  pelvic  brim,  or  can  be  pushed  above  when  labour 
comes  on,  safe  delivery  of  a  living  child  may  be  accomplished.  The 
operative  procedure  in  hystero-myomectomy,  wherein  pregnancy  is  a 
complication,  does  not  differ  in  any  essential  particular  from  the  opera- 
tion when  performed  in  uncomplicated  cases. 


404  A  TEXT-BOOK  OF  GYNECOLOGY 

Treatment:  Medicinal  and  Electrical. — Various  drugs  have  been 
recommended  as  either  curative  or  beneficial  in  the  treatment  of  fibroid 
tumours  of  the  uterus.     Such  medicinal  agents  as  ergot,  gallic  acid, 


i^iG    164. — "A   case   of  obstructive  myoma  in  which  a  successful  operation  was  done." — 

McMuETEY  (page  403). 

hydrastis,  and  some  preparations  of  iron,  have  enjoyed  favour  in  this 
capacity,  being  especially  in  repute  for  controlling  hemorrhage,  arrest- 
ing growth,  and  diminishing  the  size  of  the  neoplasm.  It  can  be  clin- 
ically demonstrated  that  such  agents  do  not  yield  the  benefits  claimed 
for  them,  while  by  impairing  digestion  and  producing  constipation  they 
are  harmful  in  their  general  influence  upon  the  system.  Fibromata 
of  the  uterus  are  so  constantly  influenced  by  circulatory  changes  in 
the  pelvic  viscera,  such  as  menstruation  and  impaired  resistance,  that 
errors  of  judgment  may  readily  be  made  by  the  overconfident  observer. 

The  results  formerly  claimed  for  deep  injections  of  ergot,  and  more 
recently  for  electrical  applications,  have  proved  misleading  and  have 
resulted  in  the  discarding  of  these  remedies.  Such  treatment  is  not 
only  inefficient,  but  positively  harmful,  in  consequence  of  the  constant 
localized  peritonitis  produced  thereby.  The  perfected  operative  treat- 
ment (Fig.  165)  of  modern  surgery  has  taken  the  place  of  all  treatment 
both  with  drugs  and  electricity.  (See  chapter  on  General  Therapeutics.) 
When  the  tumour  is  of  small  size  and  unaccompanied  by  hemorrhage 
or  other  serious  symptoms,  no  treatment  whatever  will  be  required. 
The  requirements  of  individual  cases  must  guide  the  practitioner  in 
the  determination  of  these  important  considerations. 

In  approaching  the  surgical  treatment  it  is  well  to  have  a  distinct 
understanding  of  some  of  the  terms  employed.  The  terms  myomectomy 
and  Jiystero-myomectomy  both  indicate  operative  procedures  for  the  re- 


NEOPLASMS  OF  THE  UTERUS 


405 


moval  of  fibroid  tumours  of  the  uterus.  Tlie  former  term  is  applied 
to  the  operation  in  which  the  tumour  or  tumours  are  removed  and 
the  uterus  preserved;  the  latter  indicates  the  removal  of  the  uterus  in 
part  or  in  whole  along  with  the  tumour.  Hysterectomy  properly 
denotes  removal  of  the  uterus  without  regard  to  the  presence  of  neo- 
plastic formations,  hut  is  habitually  used  as  synonymous  with  the  term 
hystero-myomectomy  in  treating  of  fibroid  tumours.  Hysterectomy 
may  be  partial  or  complete.  The  term  supravaginal  hysterectomy  is 
applied  to  amputation  of  the  uterus  at  the  internal  os,  leaving  a  cer- 


FiG.  165. — "The  perfected  operative  treatment  of  modern  surgery  has  taken  the  place  of  all 
treatment  both  with  drugs  and  electricity." — McMuktey  (page  404). 

vical  pedicle  (Fig.  166);  complete  hysterectomy,  involving  the  removal 
of  the  entire  uterus  including  the  cervix,  is  often  termed  panhyster- 
ectomy. 

Indications  for  Operation. — The  operations  for  the  removal  of 
fibroid  tumours  have  reached  a  stage  of  perfection  that  elicits  admira- 
tion and  commands  confidence.  Since  we  have  learned  to  control 
hemorrhage  in  these  operations,  the  indications  for  the  operation  have 
advanced  beyond  the  limitations  that  obtained  a  few  years  since.  Those 
who  have  practised  the  removal  of  the  ovaries  for  the  reduction  in 
size  of  a  myomatous  tumour,  or  for  the  purpose  of  staying  the  growth 
of  such  a  tumour,  know  well  that  the  convalescence  in  such  cases 


406  A  TEXT-BOOK  OP   GYNECOLOGY 

is  fraught  witli  serious  complications  that  give  the  operator  a  great 
amount  of  anxiety.  As  a  consequence  of  the  rapidity  with  which  a 
circulatory  change  takes  place  in  these  tumours  after  ablation  of  the 
ovaries,  suppuration  occasionally  sets  in,  the  tumour  begins  to  break 


Fig.  166. — "Amputation   of  the    uterus   at  the   internal    os,  leaving  a  cervical    pedicle." — 

McMuETEY  (page  405). 

down,  and  the  patient  becomes  desperately  ill.  An  experienced  oper- 
ator, therefore,  will  be  more  anxious  to  remove  fibroid  tumours  entirely 
than  to  remove  the  ovaries  alone.  It  is,  therefore,  becoming  a  serious 
question  as  to  which  operation  in  skilled  hands,  performed  according 
to  modern  methods,  is  the  more  serious  of  the  two.  That  is,  whether 
the  operation  of  abdominal  hysterectomy  or  myomectomy,  v/hen  per- 
formed for  the  removal  of  moderate-sized  tumours,  is  more  serious  than 
the  removal  of  the  ovaries  from  their  position  alongside  such  tumours. 
Indications  for  the  removal  of  such  tumours  are,  rapid  growth,  grave 
hemorrhages  from  the  uterus,  ascites,  compression  on  important  organs, 
suppuration  or  degeneration  of  the  tumour,  and  pregnancy  under 
certain  circumstances.  When  the  tumour  grows  rapidly  it  may  undergo 
malignant  degeneration,  or  become  oedematous.  Small  pedunculated 
tumours  are  not  likely  to  be  reduced  in  size  as  a  consequence  of 
the  removal  of  the  ovaries,  and  when  these  tumours  give  rise  to 
pressure  symptoms  their  removal  is  necessitated. 

General  Considerations. — The  removal  of  small  pedunculated 
growths  is  a  simple  matter.  The  uterus,  ovaries,  and  tubes,  are  left 
intact  and  the  patient  has  her  sexual  organs  practically  uninterfered 
with.  There  is  a  class  of  cases  in  which  we  may  remove  the  tumour 
by  a  process  of  enucleation  and  leave  the  uterus  intact.  We  have 
certain  tumours  deep  down  in  the  pelvis  or  in  the  broad  ligaments 
that  require  enucleation.  In  some  of  these  cases  it  is  found  impos- 
sible to  control  the  hemorrhage  without  removing  the  entire  uterus 
and  we  must  always  be  prepared  to  go  on  and  complete  the  more 
extensive  operation.  In  all  these  operations  it  is  important  that  we 
should  be  able  to  control  the  hemorrhage  with  ease  as  the  operation 
proceeds.     The  elastic  ligature  is  perhaps  the  most  valuable  aid  we 


NEOPLASMS  OF  THE  UTERUS  407 

have.  This  should  only  be  1186:1  temporarily,  and  be  aljandoned  after 
the  hemorrhage  has  been  checked  by  other  means.  A  few  years  since 
the  serre-noeud  of  Koeberle  was  used,  but  this  is  now  very  largely  dis- 
carded. The  elastic  ligature  is  passed  around  the  cervix  and  broad 
ligaments,  and  is  held  in  position  by  means  of  an  artery  forceps  placed 
upon  it  after  it  has  been  pulled  taut.  It  does  not  require  very  much 
pressure  to  control  the  hemorrhage. 

Myomectomy. — For  removing  the  jDcdunculated  fibromata  the  elas- 
tic ligature  is  placed  in  position,  a  needle  armed  with  a  double  silk 
ligature  is  then  passed  through  the  pedicle,  and  the  pedicle  is  tied 
in  half  sections.  If  the  pedicle  is  very  large  and  thick  it  is  seized  and 
compressed  by  clamp  forceps  while  the  tumour  is  cut  off,  and  care 
is  taken  to  leave  a  collar  of  peritoneum  and  capsule  large  enough 
to  permit  approximation  across  the  face  of  the  stumjo.  The  clamp 
is  then  removed  and  the  furrow  is  pierced  with  a  needle  carrying  a 
silk  suture  that  is  tied  in  several  sections.  The  edges  of  the  stump 
above  are  then  approximated  by  interrupted  sutures.  The  provisional 
elastic  ligature  is  next  removed,  and  if  there  is  much  oozing  about 
the  sutures,  a  few  deeper  ones  must  be  placed.  When  large  vessels  can 
be  seen  during  the  section  of  the  pedicle  they  are  tied  separately. 
The  pedicle  must  not  be  returned  to  the  abdomen  until  after  all 
oozing  has  ceased.  If  the  oozing  continues,  sufficient  time  must  be 
given  to  permit  of  its  arrest  by  the  adoption  of  appropriate  methods; 
and  if  it  does  not  then  cease  something  further  must  be  done.  It 
occasionally  happens  that  the  uterus,  itself,  will  require  removal  be- 
fore the  hemorrhage  can  be  controlled.  Too  much  time  and  blood 
must  not  be  lost  before  the  operator  determines  this  fact. 

Indications. — When  a  tumour  is  single,  or  when  there  are  but  two 
or  three  nodules,  the  enucleation  of  interstitial  myomata  may  be  car- 
ried out.  We  must  have  our  patients  or  their  friends  understand,  how- 
ever, that  if  it  is  impossible  to  control  the  hemorrhage  the  entire 
organ  must  be  removed.  Very  large  single  myomata  of  the  interstitial 
variety  may  be  removed  by  myomectomy  (Fig.  167). 

Some  operators  have  recommended  the  removal  of  both  ovaries  if 
other  fibrous  nodules  are  present  and  beyond  our  reach,  but  it  seems 
only  reasonable  to  suppose  that,  under  such  circumstances,  it  would 
be  better  to  remove  the  uterus  in  the  ordinary  way  by  the  method 
of  supravaginal  amputation.  Unless  the  operation  is  combined  with 
castration  there  is  always  a  danger  of  the  development  of  a  second 
tumour  that  may  be  overlooked  at  the  time  of  the  primary  operation. 
To  avoid  this  danger  it  is  necessary  to  remove  both  ovaries.  As  a  con- 
sequence, this  operation  would  seem  to  have  but  a  limited  field  in 
cases  in  which  it  is  not  desirable  to  perform  supravaginal  amputation; 
in  other  words,  it  becomes  an  operation  of  expediency. 

Many  a  young  married  woman  may  have  a  fibroid  tumour  that 
requires  removal.  She  is  willing  to  have  the  tumour  removed,  but  she 
is  not   willing  to  submit  to   the   more   radical  operation   of  removal 


408 


A  TEXT-BOOK  OF  GYNECOLOGY 


of  uterus,  ovaries  and  tubes.  A  subsequent  pregnancy  may,  it  is  true, 
endanger  her  life  owing  to  the  Aveakness  produced  in  the  uterine 
wall  by  the  enucleation  of  a  myoma,  but  if  she  is  willing  to  take  her 
chances  it  seems  but  fair  that  we  should  perform  the  operation  for 
her  in  preference  to  that  of  supravaginal  hysterectomy. 


Fig.  167  (Reed).—"  Very  large  single  myomata  of  the  interstitial  variety  may  be  removed  by 
myomectomy."^Ross  (page  407). 


Operation. — It  is  a  well-known  fact  that  these  myomata  bleed  from 
the  capsule  and  do  not  bleed  from  the  central  core,  or  tumour  proper. 
To  control  the  hemorrhage,  therefore,  it  is  necessary  to  compress  the 
capsule.  The  elastic  ligature  when  applicable  should  be  placed  i?i  situ 
before  the  primary  incision  is  made  into  the  tumour  capsule.  These 
incisions  should  be  made  in  such  a  way  as  to  wound  the  small  arterioles 
and  not  the  large  trunks.  Incisions  in  the  median  line  are  less 
liable  to  bleed  than  those  placed  to  either  side.  The  incision  must 
go  through  the  capsule  to  the  tumour  mass  (Fig.  168),  and  must  be 


neopijAsms  of  the  uterus 


409 


sufficient  to  permit  the  enucleation  of  the  tumour.  Enucleation  should 
be  done  by  a  process  of  tearing  and  not  of  cutting;  the  vessels  will, 
as  a  consequence,  bleed  less.  A  scoop,  similar  to  that  used  for  the 
removal  of  gallstones,  or  stones  from  the  urinary  bladder,  may  be 
used  as  an  enucleator.  Special  instruments  have  been  constructed  for 
this  purpose,  but  are  rarely  needed.  The  finger  and  the  handle  of 
the  scalpel  answer  admirably  as  enucleators.  Connective  tissue  will 
be  found  dipping  down  here  and  there  between  the  meshes  of  the 
tumour  and  separating  its  outer  wall  from  the  inner  surface  of  the 
capsule.  It  is  in  this  connective  tissue  that  the  enucleation  must 
be  carried  out. 

After  the  tumour  has  been  removed,  it  is  wise  temporarily  to 
loosen  the  elastic  ligature  placed  around  the  cervix,  for  the  purpose 
of  tying  vessels  that  may  be  seen  to  bleed  specially.     In  this  way 


HThOP.-diia 


.wf57-g«;;?£^  -.1  r,, 


Fig.  168  (Eeed).— "  The  incision  must  go  through  the  capsule  to  the  tumour  mass."— Eoss 

(page  408). 

all  the  large  vessels  may  be  tied  with  catgut  ligatures.  The  elastic 
ligature  can  be  again  tightened  and  the  tissues  stitched  firmly  by 
means  of  layers  of  continuous  catgut  sutures.  Finally,  the  capsule 
wall  is  brought  firmly  together  by  a  row  of  interrupted  sutures  or 
by  a  continuous  suture  of  formalinized  catgut  (Fig.  1G9).     The  elastic 


410 


A  TEXT-BOOK   OF  GYNECOLOGY 


ligature  is  finally  dispensed  with,  and  the  parts  are  watched  until  all 
bleeding  has  ceased.  It  should  be  a  fixed  rule  not  to  return  the 
uterus  to  the  abdominal  cavity  unless  bleeding  has  ceased.  One  of 
the  great  dangers  accompanying  the  operation  is  hemorrhage  into  the 
abdominal  cavity  after  the  return  to  it  of  the  uterus,  and  after  the 
relaxation  of  the  blood  vessels  has  taken  place  owing  to  the  cessation 
of  the  tension.  The  uterine  canal  may  be  laid  bare.  When  this 
is  the  case  it  is  advisable  to  place  a  small  strip  of  gauze  down  through 
the  cervix  and  pack  the  cavity  left  after  the  removal  of  the  tumour 


Fig.  169  (Eeed). — "Finally  the  capsule  wall  is  brought  iirmly  together  by  . 
suture  of  formallnized  catgut." — Ross  (page  409). 


.  a  continuous 


(Fig.  170);  or  drainage  may  be  effected  by  means  of  Eeed's  self -retain- 
ing tube  passed  from  the  tumour  nest  out  through  the  cervix  and 
vagina  (Fig.  171). 

Supravaginal  Hysterectomy. — The  difficulties  to  be  encountered 
during  the  operation  depend  upon  the  location  of  the  tumour  and 
the  extent  of  the  adhesions.  The  important  fact  to  be  remembered 
is  that  the  blood  supply  is  obtained  through  the  uterine  and  ovarian 
arteries.  These  arteries  can  readily  be  located  by  means  of  the  thumb 
and  forefinger  with  gentle  pressure.  The  pulsations  can  be  readily 
felt.  When  the  blood  vessels  have  been  located  it  is  easy  to  dissect 
down  to  them,  provided  we  do  not  cut,  but  dissect  with  the  handle 
of  the  scalpel,  into  the  cellular  tissues  of  the  broad  ligament, 
taking. care  to  avoid  the  large  veins  found  in  these  cases.  The  ves- 
sels can  be  tied  either  en  masse  or  separately  as  they  are  found. 
Just  as  we  place  a  tourniquet  upon  the  femoral  artery  before  ampu- 


NEOPLASMS  OF  THE  UTERUS 


411 


tating  the  thigh,  so  should  we  place  our  ligatures  upon  the  two  uterine 
and  two  ovarian  arteries  before  attempting  to  amputate  the  uterus. 
If  hemorrhage  then  occurs  we  may  rest  assured  that  we  have  failed 


Fig.  170  (Reed). — "  The  uterine  canal  may  be  laid  bare ;  -  .  .  place  a  small  strip  of  gauze 
clown  through  the  cervix,  and  pack  the  cavity  left  after  the  removal  of  the  tumour." — 
Eoss  (page  410). 

in  properly  securing  the  vessels.  Blood  will  flow  from  the  upper  or 
tumour  side  of  the  cut,  hut  the  proximal  side  will  be  almost  dry 
if  the  vessels  have  been  properly  tied.    If  the  uterine  cavity  is  opened, 


Fio.  171  (Kkei>;.— "Or  draiiiaLn!  may   be  eiructod   by   means  of  Kecd's  sell'-rctaining  tube 
passed  from  the  tumour  nest  out  through  the  cervix  and  vagina."— Ross  (page  410). 


412  A  TEXT-BOOK  OP   GYNECOLOGY 

it  is  wise  to  disinfect  it  with  a  little  pure  carbolic  acid  before  stitch- 
ing up  the  stump.  Some  operators  pass  down  a  small  wick  of  gauze 
through  the  cervix  into  the  vagina  to  admit  of  drainage.  The  great 
advance  that  has  been  made  in  this  surgical  procedure  is  due  to  the 
fact  that  we  depend  entirely  upon  ligation  of  the  large  blood  trunks 
supplying  the  tumour  for  the  control  of  hemorrhage,  and  that  we 
have  done  away  with  the  temporary  or  permanent  clamp.  Many 
operators  scarcely  ever  use  these  aids  to  hemostasis.  In  performing 
this  operation,  great  care  should  be  taken  to  prevent  loss  of  blood, 
to  economize  time,  and  to  avoid  subsequent  hemorrhage.  Loss  of  blood 
during  the  operation  greatly  increases  the  rapidity  of  the  patient's 
pulse;  loss  of  time  increases  the  shock;  and  loss  of  blood  after  the 
operation  will  often  prove  fatal.  It  is  never  well  to  sacrifice  thor- 
oughness for  speed,  but  there  is  a  happy  medium  to  be  obtained. 
There  is  no  operation  in  the  whole  field  of  surgery  that  requires  more 
deliberation. 

It  is  scarcely  necessary  to  describe  the  operation  as  performed  a 
few  years  since  by  means  of  the  j^ermanent  Koeberle  serre-noeud.  We 
rarely  see  the  large  ovarian  tumours  that  were  common  twenty  or 
thirty  years  ago,  because  such  tumours  are  now  removed  when  small. 
So  it  is  with  the  myomata;  they  are  removed  much  earlier  owing 
to  the  diminished  risks  of  operation. 

Technique  of  Supravaginal  Hysterectomy. — The  usual  precautions 
are  taken  in  pi-eparing  the  patient.  A  purgative  is  given  the  day 
before,  an  enema  on  the  morning  of  the  operation,  the  skin  over  the 
abdomen  is  thoroughly  disinfected,  and  the  armamentarium  of  instru- 
ments required  laid  out  in  a  convenient  place,  after  having  undergone 
thorough  sterilization.  The  patient  must  be  well  wrapped  up  on  the 
operating  table  to  prevent  chilling  of  the  body  surface. 

The  instruments  required  are:  scalpel;  large  and  small  compression 
forceps;  long-bladed  clamp  forceps;  pedicle  needle  for  transfixion;  re- 
tractors; uterine  sound;  female  bladder  sound;  heavy  silk;  catgut  in 
various  sizes;  curved  needles,  various  sizes;  needles  for  closing  abdomi- 
nal wound;  scissors;  rubber  tubing  for  elastic  ligature;  serre-noeud 
with  hysterectomy  pin;  glass  drainage  tube. 

The  abdomen  is  now  opened  by  a  free  incision.  If  adhesions  are 
encountered  great  care  must  be  taken  in  dealing  with  these,  as  the 
tumour  surface  will  bleed  at  the  points  from  which  adhesions  are 
removed.  It  is  much  wiser,  in  dealing  with  these  adhesions,  to  ligate 
them  in  two  places  and  cut  them  away,  leaving  a  ligated  portion 
still  adherent  to  the  tumour.  If  intestine  is  so  intimately  adherent 
to  the  tumour  as  to  prevent  this  procedure,  it  must  be  separated  with 
as  light  a  touch  as  possible.  Hot  cloths  placed  over  the  spots  from 
which  adherent  intestine  has  been  removed  will  control  the  hemorrhage 
while  it  is  left  in  situ.  The  tumour  is  now  raised  out  of  the  abdomen. 
Sponges  are  packed  down  above  it  to  retain  the  intestines,  and,  if 
the  incision  has  been  a  long  one,  it  is  wise  to  draw  its  edges  together 


NEOPLASMS  OF  THE  UTERUS  413 

above  the  tumour  by  means  of  one  or  two  silkworm-gut  sutures.  In 
this  way  the  intestines  are  ke2:)t  in  the  abdomen  and  out  of  the  way. 

We  must  now  outline  the  bladder  limits.  This  is  done  by  means 
of  a  sound  passed  into  the  bladder  by  an  assistant.  This  sound  is 
pushed  well  upward  until  the  upper  confines  of  this  organ  are  accu- 
rately determined.  Small  pressure  forceps  are  then  placed  a  little 
above  this  line  to  act  as  guides  to  the  position  of  the  bladder.  The 
peritoneum  is  now  incised  over  the  front  of  the  tumour,  care  being 
taken  not  to  go  deeper  than  the  peritoneum,  because  any  incision  of 
the  tumour  capsule  will  cause  hemorrhage.  By  means  of  the  finger 
and  the  handle  of  the  knife,  the  peritoneum,  with  the  bladder,  can 
then  be  easily  entirely  stripped  down  from  the  front  of  the  tumour. 
The  connective  tissue  lying  immediately  beneath  it  permits  of  this 
loosening  process.  There  is  thus  no  danger  of  wounding  the  bladder 
by  the  puncture  of  the  pedicle  needle. 

The  ovarian  artery  on  one  side  must  now  be  felt  for  and  secured, 
either  by  a  ligature  en  masse,  or  by  a  single  ligature.  If  the  single 
ligature  is  used  the  veins  must  also  be  tied  by  means  of  another  liga- 
ture. These  veins  are  always  very  much  enlarged.  A  forceps  is  now 
placed  on  the  tumour  side  of  the  mesentery  of  the  tube  to  control 
the  regurgitant  hemorrhage;  and  the  mesentery  of  the  tube,  together 
with  the  broad  ligament  at  this  point,  is  cut  across.  Should  any  bleed- 
ing point  be  found,  it  is  easy  to  control  this  hemorrhage  by  the  appli- 
cation of  another  forceps.  The  connective  tissue  close  to  the  tumour 
and  inside  of  the  veins  of  the  pampiniform  plexus  can  now  be  seen  and 
pushed  into  with  the  finger.  If  this  process  is  continued,  one  may  grope 
down  farther  until  the  uterine  artery,  whose  presence  is  made  known 
by  its  pulsations,  is  found,  and  this  artery  may  be  followed  well  down 
to  the  cervix  and  may  be  there  ligated,  either  en  masse,  or  in  a 
separate  ligature.  When  the  ligature  is  placed,  care  must  be  taken 
to  pass  the  pedicle  needle  close  to  the  cervix  uteri  and  the  loop 
should  be  carried  u^pward  and  outward  instead  of  outward,  before  it 
is  finally  tied.  In  this  way  we  avoid  inclusion  of  the  ureter.  A 
similar  procedure  is  next  followed  on  the  opposite  side.  The  blood 
supply  to  the  tumour  is  now  shut  off,  except  what  little  it  gets  through 
the  azygos  vaginae  artery  and  another  small  vaginal  branch  in  front. 
The  amputation  of  the  tumou,r  is  next  effected  with  a  few  sweeps  of 
the  knife.  It  occasionally  happens  that  one  or  two  vessels  can  be  seen 
spouting  from  the  anterior  or  posterior  surface  of  the  stump.  These 
may  be  tied  with  small  catgut  ligatures.  If,  however,  there  is  nothing 
but  a  slight  general  oozing,  the  operator  will  proceed  to  the  next  steps 
of  the  operation  for  the  control  of  this  hemorrhage. 

By  means  of  a  small  curved  needle  that  cuts  on  the  flat,  the  wound 
is  stitched  up  from  the  bottom  with  continuous  catgut  sutures;  each 
stitch  is  pulled  tightly  and  held  taut  by  the  assistant  until  the  next 
stitch  is  taken.  In  this  way  the  stump  is  gradually  built  up  and  puck- 
ered in  until  finally  the  outermost  edges  are  approximated  above  just  as 


414  A  TEXT-BOOK  OF  GYNECOLOGY 

the  two  flaps  are  brought  together  after  an  amputation  of  the  leg. 
The  peritoneum  is  stitched  together  over  the  surface,  and  this  stitch- 
ing is  continued  on  outward  over  each  broad  ligament  so  that  nothing 
but  peritoneum  can  be  seen  when  looking  into  the  pelvic  cavity. 

A  little  hemorrhage  may  have  been  found  about  the  downward 
dislocated  bladder.  If  any  vessels  persist  in  oozing  here  they  may  be 
controlled  Avitli  small  catgut  sutures.  The  mere  approximation  of 
the  bladder  back  into  its  old  position,  produced  by  the  suture  of  the 
peritoneal  edges  before  and  behind  the  stump,  is  usually  sufficient  to 
control  all  hemorrhage.  There  is  sometimes  a  little  oozing  for  three 
or  four  hours  after  the  patient  has  been  placed  in  bed,  and  on  this 
account  many  operators  place  a  glass  drainage  tube  in  the  cul-de-sac 
of  Douglas  from  above  or  from  below.  If  placed  below,  the  vagina 
is  packed  with  iodoform  gauze  to  keep  the  drainage  tube  in  situ. 
If  the  drainage  tube  is  placed  in  the  cul-de-sac  of  Douglas  from  above, 
it  should  be  removed  within  a  few  hours  after  the  operation.  Con- 
siderable blood  Avill  drain  from  it  for  two  or  three  hours,  and  then 
the  quantity  rapidly  diminishes. 

The  ligatures  used  on  the  ovarian  and  uterine  arteries  may  con- 
sist of  either  catgut  or  silk.  Some  operators  are  not  satisfied  to  use 
catgut  owing  to  the  difficulty  experienced  in  tying  it  with  sufficient 
firmness,  unless  the  gut  is  of  such  a  thickness  as  to  make  it  difficult 
to  completely  sterilize  it.  Silk,  if  used,  should  not  be  any  heavier 
than  is  necessary  to  accomplish  the  purpose  for  which  it  is  intended. 
If  the  silk  is  of  the  first  quality  a  much  smaller  strand  can  be  used  than 
if  it  is  of  an  inferior  quality. 

If  hemorrhage  still  continues  after  the  stump  has  been  stitched 
together  in  the  manner  described,  it  is  sometimes  necessary  to  transfix 
lower  down  and  tie  the  stump  with  very  strong  thread  into  two 
sections.  This  procedure  can,  however,  scarcely  be  called  for  if  the 
arteries  have  been  properly  ligated  in  the  commencement  of  the  opera- 
tion. AYhen  such  hemorrhage  occurs,  the  arteries  may  be  sought  for 
and  an  efl^ort  made  to  find  the  presence  or  absence  of  pulsation  beyond 
the  ligatures.  It  may  even  be  advisable  to  throw  another  ligature 
around  any  or  all  of  the  vessels  to  insure  their  constriction,  as  the 
placing  of  a  loop  about  the  whole  pedicle  may  produce  sloughing  of 
the  tissue.     Ross  has  seen  this  occur  in  one  case. 

Extra-peritoneal  Treatment  of  the  Pedicle. — If  it  is  decided  to  treat 
the  pedicle  according  to  an  extra-peritoneal  method,  the  technique 
of  the  first  part  of  the  operation  is  exactly  similar  to  that  just  de- 
scribed. The  vessels  are  ligated  and  the  wire  clamp  is  then  passed 
down  around  the  pedicle,  inside  of  and  above  the  broad  ligaments 
that  have  now  been  divided  and  pushed  away.  A  single  or  double 
pin  is  then  pushed  through  the  stump  to  hold  it  outside  the  abdominal 
cavity  and  to  keep  the  wire  from  slipping  ofi'  the  pedicle.  The  wire 
is  then  tightened  up  and  the  tumour  rapidly  removed.  The  wound 
is  next  closed  about  the  stump  so  that  the  peritoneal  surface  of  the 


NEOPLASMS  OP  THE  UTERUS  415 

stump  comes  in  contact  with  the  parietal  peritoneum.  The  perito- 
neal cavity  is  thus  shut  off  by  adhesions  in  a  few  hours.  The 
bladder  must  be  carefully  dissected  down  and  pushed  out  of  the  way, 
in  order  that  injury  to  the  bladder  and  ureters  by  the  wire  of  the 
clamp  may  be  avoided.  These  unfortunate  accidents  have  occurred 
on  several  occasions.    Intestine  must  also  be  kept  well  out  of  the  way. 

The  stump  is  now  tanned  with  a  solution  of  perchloride  of  iron 
and  glycerine,  and  covered  with  strips  of  dry  lint.  The  serre-noeud 
is  tightened  frequently,  and  the  pedicle  sloughs  off  about  the  twelfth 
day,  leaving  a  granulating  surface  that  requires  several  weeks  to 
heal. 

The  so-called  mummification  of  the  stump  is  not  of  very  great 
importance.  Even  though  the  stump  mummifies,  the  tissues  under- 
neath frequently  suppurate. 

Another  extra-peritoneal  method  of  dealing  with  the  pedicle  is  that 
by  which  it  is  transfixed  and  tied  with  chain  suture,  and  then  fastened 
in  the  abdominal  wound  without  the  use  of  any  clamp.  As  a  con- 
sequence of  the  position  of  the  pedicle,  this  method  prevents  union  of 
the  abdominal  incision  by  first  intention  and  permits  of  a  subsequent 
hernia  through  the  abdominal  parietes.  There  is  nothing  to  be  gained 
by  leaving  the  pedicle  in  this  situation.  It  was  supposed  that  it  could 
be  readily  lifted  up  and  hemorrhage  could  be  easily  controlled,  but 
this  has  proved  to  be  an  unnecessary  precaution  now  that  the  ligation 
of  the  vessels  is  better  understood.  A  great  deal  of  this  sort  of  surgery 
can,  with  profit,  be  relegated  to  the  past  though  it  has  all  served  a 
useful  purpose. 

The  ideal  operation,  described  above,  is  all  that  can  be  required 
for  the  removal  of  fibroid  tumours  where  they  occupy  a  i^osition  in 
the  fundus,  or  press  outward  into  the  broad  ligament  or  into  the 
pelvis.  All  can  be  removed  by  this  procedure  with  ease  and  safety  by 
experienced  operators.  At  this  stage  of  our  knowledge,  it  is  useless 
to  recount  the  different  methods  adopted  by  different  operators  during 
the  past  ten  or  fifteen  years.  Most  of  these  methods  have  been  dis- 
carded, or,  if  they  have  not  been  discarded,  they  should  have  been. 

Panhysterectomy,  as  the  name  implies,  means  the  complete  extir- 
pation of  the  uterus.  In  practice,  the  ovaries  and  Fallopian  tubes  are 
generally,  although  not  always,  removed  with  the  uterus.  A  number 
of  operators  recommend  in  this,  as  in  other  operations  for  the  removal 
of  the  uterus,  that  an  ovary,  if  entirely  healthy,  be  left  in  situ,  for 
the  purpose  of  maintaining  the  menstrual  molimen  and  of  mitigating 
the  nervous  symptoms  that  frequently  follow  complete  ablation  of  the 
genital  apparatus. 

The  technique  of  this  operation,  as  practised  by  Ross,  is  similar 
to  that  described  for  the  removal  of  the  myomatous  uterus  by  supra- 
vngirifil  amputation,  ''.llie  cervix  may  readily  be  removed  after  the 
liKiiour  has  been  cut  away  and  is  no  longer  obstructing  the  view.    The 


416 


A  TEXT-BOOK  OF   GYNECOLOGY 


vessels  supplying  the  cervix  are  the  same  as  those  supplying  the 
vaginal  wall  at  its  junction  with  the  cervix,  provided  that  the  blood 
supply  from  the  uterine  arteries  has  been  cut  off.  We  may,  therefore, 
expect  to  find  the  azygos  vaginae  artery  spouting  when  the  vaginal 


Fig.  172. — "  The  small  clamf)s  attached  to  the  uterus  are  now  hooked  up  by  two  fingers  of  the 
left  hand,  by  which  traction  is  made." — Eeed  (page  417). 


septum  is  cut  through  at  its  junction  with  the  cervix  in  the  neigh- 
bourhood of  the  cul-de-sac  of  Douglas.  No  vessels  of  importance  will 
bleed  on  either  side,  but  another  small  branch  or  two  will  be  found 


NEOPLASMS  OF  THE   UTERUS 


417 


spouting  in  the  vaginal  septnin,  where  it  is  separated  from  the  uterine 
neck  in  front.    These  vessels  can  be  readily  ligated  with  catgut. 

Reed's  operation  of  panhysterectomy  is  as  follows:  All  adhesions 
of  the  uterus  and  its  appendages  are  first  broken  up  and  the  uterus 
is  lifted  up  into  the  abdominal  incision.  In  some  cases  this  manipula- 
tion can  be  done  so  satisfactorily  with  the  patient  upon  her  back  that 
it  is  unnecessary  to  put  her  in  the  Trendelenburg  position,  although 
in  most  cases  the  latter  posture  is  not  only  desirable  but  necessary. 
The  broad  ligament  is  then  clamped  upon  one  side,  just  beneath  the 
ovary  and  Fallopian  tube,  the  clamp  extending  from  the  margin  of  the 
broad  ligament  to  the  side  of  the  cervix.  Another  and  smaller  clamp 
is  now  placed  on  the  broad  ligament  parallel  with  the  previous  clamp 
but  a  quarter  of  an  inch  nearer  to  the  uterus.  The  broad  ligament 
is   then  divided  between   the   clamps,  from   its   edge   to  the  side   of 


Fig.   173.—"  The   uterine   arteries   which   can   be   seen   and   clamped   as  soon  as  they  are 

reached." — Keed. 


the  cervix;  the  broad  ligament  on  the  other  side,  is  similarly  clamped 
and  incised.  The  vesical  fold  of  the  peritoneum  is  now  dissected  away 
from  the  front  of  the  uterus,  as  is  the  peritoneum  covering  the  pos- 
terior side  of  the  organ.  The  small  clamps  attached  to  the  uterus 
are  now  hooked  up  by  two  fingers  of  the  left  hand,  by  which  trac- 
tion is  made  (Fig.  172).  As  the  uterus  is  drawn  away  from  the  vagina, 
the  dissection  is  made  by  means  of  the  scissors  held  in  the  right  hand. 
Care  should  be  taken  in  making  this  dissection  to  avoid  wounding  the 
uterine  arteries,  which  can  be  seen  and  clamped  as  soon  as  they  are 
reached  (Fig.  173).  From  this  time  on,  the  dissection  should  be  carried 
even  more  closely  to  the  cervix,  dividing  the  cervical  tissues  sufficiently 
to  leave  a  slight  ring  in  situ  after  the  cervix  is  withdrawn.  If  this 
precaution  is  not  taken,  there  is  liability  of  wounding  the  azygos  vaginae 
28 


418 


A  TEXT-BOOK  OF   GYNECOLOGY 


artery,  the  hemorrhage  from  which,  while  controllable,  is  embarrassing. 
When  the  vagino-cervical  juncture  has  been  reached,  the  point  of  the 
closed  scissors  may  be  thrust  through  into  the  vaginal  canal.  After 
this  preliminary  opening,  the  remaining  division  of  the  vaginal  mucosa 
is  accomplished  with  facility.  The  ovarian  and  the  uterine  arteries 
upon  either  side  are  next  tied  individually  by  means  of  formalinized 
catgut.  All  clamps  are  now  removed,  and  the  field  of  operation  is 
inspected  to  make  sure  of  complete  arrest  of  the  bleeding.  If  this  is 
duly  controlled,  a  piece  of  sterilized  gauze  is  packed  into  the  vagina  from 
above,  the  upper  part  of  the  pack  coming  within  and  above  the  cut 
margins  of  the  vaginal  mucous  membrane.  The  peritoneal  margins 
are  stitched  together  by  means  of  a  continuous  catgut  suture.  Finally, 
the  toilet  of  the  peritoneum  is  made  by  means  of  dry  sponging,  and 
the  incision  is  closed  by  laminated  sutures.  (See  Abdominal  Section.) 
The  specimen  removed  will  show  a  complete  uterus  with  the  append- 
ages and  the  exact  area  of  the  dissection  (Fig.  174). 

If  it  is  desired  to  use  the  angeiotribe  for  hemostasis,  it  can  be 
applied  just  beneath  the  temporary  clamp,  which  is  then  removed. 


Fig.  174. — "  The  specimen  removed  will  show  a  complete  uterus  with  appendages  and  the 
exact  area  of  the  dissection." — Eeed. 


Care  should  be  taken  that  the  end  of  the  angeiotribe  shall  embrace 
the  uterine  artery  within  its  clasp  (Fig.  175).  The  instrument  should 
be  left  on  a  few  minutes,  when  it  can  be  applied  similarly  to  the 
other  side.     Doyen,  who  invented  the  angeiotribe,  does  not  trust  it 


NEOPLASMS  OF  THE  UTERUS  419 

alone  to  control  hemorrhage  under  these  circumstances,  but  applies  a 
supplementary  ligature,  asserting  as  a  sufficient  advantage  for  using 
the  instrument  that  it  diminishes  the  volume  of  the  tissues  and  renders 
less  liable  slipping  of  the  pedicle.     The  electric  clamp  of  Skene  may 


Fig.  175.^"  If  it  is  desired  to  use  the  angeiotribe  for  hemostasis,  it  can  be  applied  just  beneath 
the  temporary  clamp,  which  is  then  removed.  Care  should  be  taken  that  the  angeiotribe 
shall  embrace  the  uterine  artery  within  its  clasp." — Eeed  (page  418). 

be  similarly  employed  (see  Hemostasis),  but  whether  forcipressure  or 
heat  is  applied  for  hemostasis,  the  peritoneal  margins  should  be  stitched 
together  to  avoid  retraction. 

The  advantages  of  panhysterectomy  are  (a)  the  contamination  of 
the  field  of  operation,  which  is  so  liable  to  happen  as  the  result  of 
extension  of  infection  from  the  endocervium  in  cases  of  supravaginal 
amputation,  does  not  occur;  (b)  drainage  by  the  vagina  is  easily  and 
thoroughly  accomplished;  (c)  with  care  in  avoiding  the  azygos  vagina 
artery,  hemostasis  is  readily  secured  and  safely  maintained.  The  re- 
sulting condition  of  the  pelvic  diaphragm  is  one  of  equal,  if  not  greater, 
strength  than  that  secured  by  the  supravaginal  operation;  {d)  if  the 
technique  above  described  is  carefully  followed,  the  operation  is  done 
with  greater  facility  than  are  others  devised  for  the  extirpation  of 
the  uterus;  (e)  myomatous  uteri  of  considerable  magnitude  may  be 
removed,  en  masse,  by  this  means  (Fig,  176). 

Vaginal  hysterectomy  is  sometimes  practised  for  the  removal  of 
small  fliU'u.se  jiiycjmaia  of  the  uterus,  associated  with  persistent  and 


420 


A  TEXT-BOOK  OF  GYNECOLOGY 


uncontrollable  hemorrhage.  The  technique  of  the  operation  does  not 
differ  from  that  described  in  connection  with  malignant  neoplasms  of 
the  uterus.    (See  Vaginal  Hysterectomy.) 

Vaginal  Myomotomy. — (a)  Enucleation  (technique). — The  tumours 
most  appropriate  for  enucleation  are  small  and  medium-sized,  single 


Fig.  176. — "  Myomatous  uteri  of  considerable  magnitude  may  be  removed,  en  masse,  by  this 

means." — Reed  (page  419). 

submucous  tumours  that  are  not  pedunculated,  and  interstitial  tumours 
distinctly  encapsulated  and  projecting  well  into  the  cavity;  also  large 
tumours  projecting  into  the  os  or  partly  extruded  from  the  same. 
Very  large  tumours,  if  removed  by  vaginal  myomotomy,  are  best  ex- 
tirpated by  morceUement  or  by  combined  morcdlement  and  enucleation. 
The  cervical  fibroids  requiring  enucleation  are  of  rare  occurrence. 
They  may  be  extirpated  as  a  rule  without  difficulty.  After  exposing 
them  by  means  of  a  Sims's  speculum  and  retractors,  an  ample  incision 
is  made  through  the  covering  of  the  tumour,  which  covering  is  sepa- 
rated from  the  tumour  with  the  finger  or  handle  of  the  knife  (Fig.  177); 
then  the  uncovered  portion  of  the  tumour  is  seized  with  a  strong  volsella 
forceps  and  traction  upon,  and  rotation  of,  the  neoplasm  is  made,  while 


NEOPLASMS  OF   THE   UTERUS 


421 


the  finger  is  inserted  between  the  tumour  and  its  envelopes,  to  sever  its 
cellular  connections.  Should  there  be  any  dense  bands  of  tissue  ex- 
tending from  the  tumour  into  the  underlying  tissues,  they  should  be 
severed  with  scissors.  Emmet's  right-hand,  lesser-curved,  blunt- 
pointed  scissors,  serve  as  an  excellent  substitute  for  the  finger,  and 
are  ready  at  hand  if  needed  to  sever  any  bands.  No  great  difiiculty 
presents  and  there  is  as  a  rule  little  hemorrhage.  If  needed,  hot- 
water  irrigation  and  packing  the  cavity  with  gauze  will  arrest  bleeding. 

When  the  neoplasm 
to  be  enucleated  is  situ- 
ated within  the  uterine 
cavity,  it  is  a  matter  of 
the  first  importance  that 
the  OS  be  widely  dilated. 
This  may  be  effected  by 
laminaria  tents,  the  steel 
dilator,  or  by  lateral 
incisions  of  the  cer- 
vix. The  last  method  is 
preferable.  The  various 
steps  of  the  operation 
may  be  stated  as  follows: 
The  patient  is  placed  in 
the  dorsal  position,  with 
legs  in  holders  or  feet  se- 
cured in  the  high  stir- 
rups, and  with  buttocks 
projecting  slightly  be- 
yond the  edge  of  the 
table.  She  has  been  pre- 
viously prepared.  Wash 
out  the  vagina  again  with 
a  bichloride  solution;  re- 
tract the  perineum  with 
a  self  -  retaining  specu- 
lum, preferably  a  Jones's 
with  a  short  blade. 
Now  seize  the  anterior  lip 
of  the  cervix  with  bullet 

forceps  and  pull  down  the  uterus.  Incise  the  os  with  scissors  or  knife. 
Examine  the  tumour  to  determine  its  size  and  location,  make  ample 
incision  through  its  covering  over  the  most  dependent  accessible  part. 
Separate  the  envelopes  from  the  tumour  for  a  short  distance,  and 
seize  the  neoplasm  with  a  strong  short-tined  volsella  or  Museiix  for- 
ceps. Now  proceerl  as  indicated  in  describing  the  method  of  enucleat- 
ing the  cervical  fibroid.  Thomas's  serrated  spoon  saw  (Fig.  178)  will 
often  be  found  serviceable  in  loosening  the  tumour  attachments.     Con- 


FiG.  177. — "  An  ample  incision  is  made  through  the  cov- 
ering of  the  tumour,  which  covering  is  separated  from 
the  tumour  with  the  finger  or  handle  of  the  knife."— 
Dunning  (page  420). 


422 


A   TEXT-BOOK   OF  GYNECOLOGY 


i 

h'lG.  178. 
"  Thomas's 

serrated 
spoon  saw." 
— Dunning 
(page  421). 


siderable  force  may  be  required  to  dislodge  the  tumour.     Strong  trac- 
tion may  be  employed,  but  the  danger  of  lacerating  the  uterine  walls 
or  producing  inversion  of  the  organ,  must  be  borne  in  mind.     If  the 
tumour  is  too  large  to  be  delivered  whole,  it  may  be  cut 
into  sections  and  removed  piecemeal. 

(b)  Morcellement. — When  the  tumour  is  very  large,  this 
method  may  be  employed  in  preference  to  enucleation. 
Emmet  is  given  the  credit  of  priority  in  describing  and 
putting  into  execution  a  systematic  method  of  vaginal 
myomotomy  by  morcellement.  It  has  often  been  denomi- 
nated Emmet's  traction  method,  but  it  comprises  most  of 
the  essential  features  of  what  is  known  to-day  as  vaginal 
extirpation  by  morcellement.  It  differs  from  enucleation  in 
that  after  dilatation  of  the  os,  no  effort  is  made  to  divide 
the  capsule  of  the  tumour,  and 
sections  of  the  neoplasm  are 
made  in  the  vagina.  The  neo- 
plasm is  seized  at  its  lower  por- 
tion with  strong  hooks  or  vol- 
sella  forceps  and  forcibly  drawn 
downward.  As  it  descends  into 
the  vagina,  portions  of  the  tu- 
mour are  cut  away  and  removed, 
the  remaining  portion  is  again  seized  and 
powerfully  drawn  upon,  and  once  more  the 
presenting  part  is  cut  away.  And  so  the 
process  is  carried  on,  until  finally  the  base 
of  the  tumour  is  reached.  It  will  now  be 
observed  that,  in  consequence  of  the  power- 
ful traction,  a  pedicle  has  been  formed 
which,  in  some  of  Emmet's  cases,  was  no 
larger  than  the  index  finger  and  consisted 
of  the  coverings  of  the  tumour.  This  base 
is  severed  and  the  last  of  the  tumour  is  re- 
moved. The  traction  upon  the  tumour 
stimulates  uterine  contraction,  so  that  as 
the  tumour  descends,  the  uterus  follows, 
closely  encircling  the  neoplasm.  If  neces- 
sary, the  descent  of  the  uterus  may  be  aided 
by  pressure  upon  the  fundus  from  above  the 
pubes.  Injections  of  hot  water  into  the 
cavity  of  the  uterus  may  be  made  if  needed 
to  stimulate  contraction  or  to  arrest  hemor- 
rhage. In  case  of  profuse  hemorrhage  dur- 
ing the  process  of  extirpation,  the  tumour  should  be  removed  as  quickly 
as  possible,  hot-water  injections  employed,  and  later,  if  necessary,  gauze 
packing. 


Fig.  179. — Pean's  forceps  for  mor- 
cellement.— Dunning  (page  428). 


NEOPLASMS  OP  THE  UTERUS  423 

Pean's  method  of  morcellement  differs  little  in  principle  from  Em- 
met's, the  chief  differences  being  in  the  use  of  specially  devised  instru- 
ments (Fig.  179),  the  j)reliminary  severing  of  the  vaginal  and  other 
attachments  of  the  cervix  as  high  as  the  lovi^er  margin  of  the  tumour, 
and  the  excision  of  the  lips  of  the  cervix  and  application  of  pressure 
forceps  to  bleeding  vessels  within  the  uterine  cavity,  if  the  hemorrhage 
is  profuse. 

The  following  is  a  brief  summary  of  Pozzi's  {Medical  and  Sur- 
gical Gynecology,  vol.  i,  pp.  267-272)  excellent  and  elaborate  descrip- 
tion of  Pean's  method: 

1.  Liberate  the  cervix  by  circular  incision.  Check  hemorrhage  by 
application  of  pressure  forceps. 

2.  Incise  the  cervix  bilaterally  from  the  cervical  canal.  Incise  the 
lower  segment  of  the  uterus  if  necessary  to  the  level  of  the  tumour. 

3.  Seize  the  anterior  and  posterior  lips  of  the  uterus  with  forceps 
and  draw  the  organ  toward  the  vaginal  outlet. 

4.  Seize  the  most  accessible  portion  of  the  tumour  with  forceps, 
drag  it  downward  and  cut  off  a  section.  Seize  the  accessible  portion 
again,  drag  downward  and  cut  away  another  piece.  Repeat  this  pro- 
cedure until  finally  the  remainder  of  the  tumour  comes  within  reach. 
Now,  if  pedunculated,  sever  the  pedicle  and  remove  the  last  of  the 
tumour.  If  more  easily  effected,  enucleate  the  remaining  mass.  Search 
for  other  tumours;  if  any  are  found,  extirpate  them  in  like  manner. 
If  there  is  no  hemorrhage,  irrigate  the  uterine  cavity  with  a  hot  anti- 
septic solution  and  place  one  or  two  strips  of  gauze  for  drainage. 
Stitch  the  incised  cervix.  Stitch  the  incised  vaginal  walls  to  the 
cervix  and  pack  the  vagina  lightly  with  gauze. 

If  there  is  prolonged  hemorrhage  not  checked  by  hot  irrigation, 
excise  the  lips  of  the  cervix,  draw  the  uterus  down  to  the  vaginal 
outlet,  mop  out  the  uterine  cavity,  seize  the  bleeding  vessels  with 
long  catch  forceps  and  pack  the  uterine  cavity  lightly  with  gauze.  As 
a  final  step,  stitch  the  lower  end  of  the  uterus  to  the  incised  vaginal 
walls. 

Both  Emmet's  and  Pean's  operations  in  cases  of  large  tumours 
are  formidable  and  may  in  many  instances  be  rejected  in  favour  of 
vaginal  or  supravaginal  hysterectomy.  They  are  contraindicated 
when  the  uterus  contains  several  tumours,  and  when  there  is  suppura- 
tive disease  of  the  uterine  adnexa. 

In  view  of  the  fact  that  foci  of  fibroid  development  may,  and 
often  do,  exist  in  such  size  and  localities  as  to  defy  detection  in  the 
remaining  uterine  wall;  and  in  view  of  the  frequent  recurrence  of 
fibromyomatous  growths  in  uteri  which  have  been  subjected  to  myo- 
mectomy, many  o])erators,  with  good  cause,  reject  the  latter  operation. 
It  is  undeniable  that  hysterectomy  is  to  be  preferred  in  the  majority 
of  cases.  It  is  argued  that  myomectomy  is  always  a  serious  operation, 
that,  as  already  stated,  it  often  fails  to  bring  the  patient  immunity,  and 
that  there  is  difficulty  in  detecting  other  commencing  growths.     This 


424  A  TEXT-BOOK  OF  GYNECOLOGY 

is  all  avoided  by  hysterectomy,  the  immediate  dangers  from  which  are  no 
greater  than  from  myomectomy.  It  is  true  that  a  few  women  have 
conceived  and  borne  children  after  myomectomy,  but  this  result  is 
rare;  sterility  or,  in  the  event  of  conception,  abortion  may  be  set 
down  as  of  commoner  occurrence. 

Extirpation  of  Polypoid  Growths  from  the  Uterus. — The  method  of 
removal  of  a  small  polypus  attached  at  or  near  the  external  os  is 
simple.  With  a  strong,  long-handled  catch  forceps  seize  the  pedicle 
near  its  attachment,  and  by  traction  on  and  rotation  of  it,  the  attach- 
ment is  broken  up.  But  little  force  is  required,  and  little  bleeding 
need  be  feared,  unless  too  strong  traction  has  been  exerted.  Should 
hemorrhage  appear,  it  is  best  to  cauterize  the  bleeding  surface,  if  acces- 
sible, with  the  thermo-cautery.  If  the  pedicle  is  broad  and  the  polypus 
vascular,  incise  the  base  with  scissors  and  cauterize  the  cut  surfaces 
with  the  thermo-cautery. 

When  the  polypus  is  large,  distending  the  vagina  and  obscuring 
a  view  of  the  pedicle,  the  point  of  attachment  and  the  size  of  the 
pedicle  should  if  possible  be  determined.  This  can  usually  be  effected 
by  a  digital  exploration,  or,  if  the  polypus  is  too  large  to  permit  this, 
a  bent  uterine  sound  can  usually  be  carried  round  and  above  the 
polypus,  when,  by  manipulation,  the  attachment  can  be  felt  and  its 
size  estimated.  The  loop  of  the  wire  ecraseur  may  be  carried  around 
the  tumour  and  the  whole  instrument  gently  carried  upward  toward 
the  cervix.  If  a  strand  of  piano  wire  is  used,  there  is  usually  little 
difficulty  in  encircling  the  pedicle.  By  leaving  one  end  of  the  wire 
unfastened  until  the  pedicle  is  reached,  it  may  then  be  drawn  tight 
and  the  unfastened  end  of  the  wire  wrapped  around  the  post  of  the 
ecraseur,  when  a  few  turns  of  the  screw  will  sever  the  pedicle. 

Sometimes  the  polypus  will  be  so  large  that  difficulty  is  experi- 
enced in  delivering  it.  Two  courses  are  then  open — namely,  section 
of  the  tumour  and  its  delivery  piecemeal,  or  the  application  of  an 
obstetrical  or  a  specially  designed  forceps  with  which  to  make 
traction. 

When  the  attachment  of  the  pedicle  is  above  the  internal  os  and 
the  tumour  presents  at  the  external  os  or  protrudes  into  the  vagina, 
the  polypus  may  frequently  be  seized  with  a  forceps  or  tenaculum, 
traction  made  upon  it,  and  the  pedicle  cut  with  scissors.  No  fear 
of  hemorrhage  or  recurrence  of  the  polypus  need  be  entertained.  If 
the  polypus  is  wholly  within  the  internal  os,  it  is  probable  that  the 
tumour  is  large  or  the  pedicle  short.  To  accomplish  its  removal,  the 
cervical  canal  should  be  dilated  by  the  steel  dilator,  or  the  cervix  may 
be  incised  and  subsequently  dilated  by  the  finger  or  steel  dilator.  None 
of  these  procedures  is  objectionable  if  conducted  under  antiseptic  pre- 
cautions. With  the  cervix  dilated,  the  anterior  lip  may  be  seized 
with  a  double  tenaculum,  the  uterus  drawn  down,  and  the  interior 
of  the  uterus  explored  with  the  finger. 

In  this  way  small  polypi  may  be  located  and  scraped  off  with  a 


NEOPLASMS  OF  THE  UTERUS  425 

sharp  curette  or  cut  off  with  long  blunt  scissors.  It  has  been  Dun- 
ning's  practice  for  many  years  when  the  pedicle  could  be  distinctly 
located  and  safely  reached  by  blunt-pointed  scissors  to  sever  it  with 
scissors  in  all  cases  of  uterine  polypi  attached  above  the  internal  os. 
Should  the  tumour  be  very  vascular  and  contain  a  large  artery,  a 
safe  and  feasible  plan  is  to  seize  the  pedicle  in  the  bite  of  a  long- 
curved  pressure  forceps  and  sever  it  between  the  forceps  and  the  tumour. 
The  forceps  should  be  allowed  to  remain  attached  to  the  stump  of  the 
pedicle  for  two  days.  A  large  polypus  with  a  short,  thick,  pedicle 
attached  high  up  can  be  best  extirpated  by  severing  the  pedicle  with 
a  wire  ecraseur. 

In  all  cases  of  intrauterine  polypi,  after  the  removal  of  one  polypus 
the  cavity  of  the  uterus  should  be  explored,  for  occasionally  more  than 
one  growth  is  present.  Should  hemorrhage  follow  the  extirpation  of 
the  polypus  from  this  region,  the  intrauterine  douche  of  hot  water  will 
usually  arrest  it.  Vinegar,  in  proportion  of  1  to  3  or  1  to  2  is  a  valuable 
addition  to  the  douche.  If  these  plans  fail,  the  uterine  cavity  should 
be  packed  with  plain  sterilized  or  chemically  asepticized  gauze.  The 
operators  may  choose  between  the  Sims  and  dorsal  positions.  Dun- 
ning and  many  other  operators  prefer  the  latter,  with  the  limbs  in 
the  holders  and  the  cervix  exposed  by  a  short,  broad,  Sims's  or  Jones's 
speculum.  The  removal  of  malignant  polypoid  growths  has  not  been 
considered  in  tlie  foregoing  remarks.  They  are  best  treated  by  total 
extirpation  of  the  uterus.  (See  Malignant  Neoplasms  of  the  Uterus 
and  Vaginal  Hysterectomy.) 


CHAPTER    XXIX 

NEOPLASMS   or   THE   UTERUS   (Continued) 

Malignant  neoplasms:  (a)  Syncytionia  malignum;  {i)  adenoma;  (c)  sarcoma;  (d) 
carcinoma — Treatment:  (a)  Palliative:  topical  medication,  curettement,  high 
amputation;  (b)  radical:  vaginal  hysterectomy;  abdomino-vaginal  panhyster- 
ectomy; the  extended  operation;  electro-hysterectomy — Results. 

Malignant  Neoplasms  of  the  Utekus 

These  will  be  considered  in  the  following  order:  (a)  syncytioma 
malignum,  (h)  adenoma  uteri,  (c)  sarcoma  iiteri,  {d)  carcinoma  uteri, 
(e)  exceptional  forms. 

These  growths,  while  differing  in  their  histogenesis  and  in  their 
histologic  properties,  have  in  common  the  clinical  feature  of  malig- 
nancy; they  are,  therefore,  neoplasms  which,  if  left  to  themselves,  will 
kill  the  patient  by  progressive  invasion  of  tissue  and  by  local  and  con- 
stitutional conditions  that  are  thereby  established.  These  changes  will 
be  described  in  detail  in  connection  with  the  different  diseases.  It  is 
desirable,  in  this  preliminary  paragraph,  to  emphasize  the  statement 
that  the  treatment  of  malignant  neoplasms,  to  be  curative,  must  involve 
the  complete  eradication  of  the  growth.  In  view  of  the  inherent  ten- 
dency of  these  growths  to  invade  the  neighbouring  tissues,  some  slowly, 
others  rapidly,  the  operation  should,  manifestly,  be  undertaken  as  soon 
as  the  malignant  character  of  the  growth  is  determined.  So  long  as 
the  neoplasm  remains  within  operable  limits,  nothing  short  of  its  com- 
plete extirpation  should  be  contemplated  or  attempted.  When,  how- 
ever, it  has  passed  the  operable  limit,  and  has  invaded  structures  and 
organs  that  can  not  be  dealt  with  surgically  without  an  immediate  fatal 
issue,  the  patient  should  be  subjected  to  palliative  treatment.  The 
rule  formerly  entertained  and  adopted,  that  mild  measures  should  be 
employed  in  incipient  cases  and  radical  measures  only  in  advanced 
cases,  should  in  the  interest  of  humanity  be  absolutely  reversed. 

Syncytioma  malignum,  known  also  as  deciduoma  malignum,  malig- 
nant placentoma,  carcinoma  syncitiale,  sarcoma  deciduo-cliorio-cellulare, 
deciduo-sarcoma,  cJiorio-epitheliom^a,  is  a  degenerative  malignant  disease 
of  the  sarcomatous  type,  originating  in  the  decidual  structures  of  the 
pregnant  woman,  and  tending  to  a  rapidly  fatal  issue  (Fig.  180). 

Maier  published  in  VircJioiv's  Archives  for  1875  two  observations  on 
tumours  of  the  body  of  the  uterus;  the  tissue  composing  the  tumours 
426 


NEOPLASMS   OF   THE   UTERUS 


427 


was  distinctly  decidual  in  character.  Hegar  subsequently  reported 
the  death  of  one  of  these  patients  from  what  he  considered  to  be 
cancer  of  the  uterus.  Sanger,  in  1888,  was  the  first  to  demonstrate 
this  disease,  and,  in  1893,  to  draw  attention  to  its  essential  histoge- 
netic  character  and  to  its  pronounced  malignant  tendency.  A  number 
of  cases  have  since  been  reported  in  various  countries,  and  special 
studies  of  the  disease  have 
been  made  by  Whitridge 
Williams  in  America  {Amer- 
ican Journal  of  Gynecology 
and  Oistetrics,  June,  1895), 
and  Eoger  Williams  in  Eng- 
land. Maurice  Cazin  {La 
Gynecologic,  February,  1896) 
made  a  careful  study  of  the 
disease  and  did  much  to 
elucidate  its  jDathology.  The 
literature  of  the  subject  has 
already  grown  voluminous. 

Pathology.  ■ — •  These  tu- 
mours of  the  uterus  when 
first  observed  gave  rise  to  a 
great  deal  of  confusion  as  to 
their  true  nature  and  histo- 
genetic  classification.  There 
are    not   yet    a   great    many 

cases  of  this  kind  on  record,  because  our  attention  has  only  recently 
been  drawn  to  them.  Syncytioma  is  found  in  the  uterus  after  delivery 
at  full  term,  abortion,  or  mole  pregnancy.  It  forms  soft  tumours,  bleed- 
ing easily,  variable  in  size,  generally  roundish  and  small,  very  malig- 
nant, and  with  a  tendency  to  form  early  distant  metastases.  The  sub- 
ject of  these  tumours  has  been  treated  in  our  country  in  articles  by 
Bacon,  Williams,  and  Gaylord.  These  neoplasms  are  derived  from  the 
chorion  epithelium  of  the  placenta  and  they  are  therefore  of  foetal 
origin.  On  account  of  this  fact  they  form  one  of  the  most  peculiar 
malignant  neoplasms  met  with.  We  have  here  a  tumour  spreading  in 
the  mother,  which  has  taken  its  origin  from  foetal  structures.  There 
are  of  course  quite  a  number  of  writers  who  assert  that  the  syncytium  of 
the  placenta  is  of  maternal  origin.  Herzog,  from  his  own  work  on  the 
histology  of  the  placenta  and  from  the  recent  contributions  of  Van 
Heukelom,  His,  Peters,  and  others,  is  convinced  that  the  syncytium  is 
derived  from  the  foetal  ectoderm,  and  he  therefore  classifies  syncytioma 
malignum  under  epiblastic  epithelial  neoplasms. 

Histology. — The  tissue  of  these  tumours  shows  protoplasmic  masses 
in  which  are  seen  many  nuclei,  without,  however,  any  cell  boundaries 
being  recognisable.  Those  masses  very  much  resemble  syncytial  buds 
(Fig.  181).    There  are  also  found  cells  having  the  character  of  those 


Fig.  180. — "  Syncytioma  malignum  ...  is  a  de- 
generative malignant  disease  of  the  sarcomatous 
type." — Heezog  (page  426). 


428 


A  TEXT-BOOK  OF  GYNECOLOGY 


Fig.  181. — "  These  masses  very  much 
resemble  syncytial  buds." — Herzog 
(page  427). 


of  the  Langhan's  layer  of  the  normal  placental  villi.  Between  the 
tracts  of  tumour  cells  are  large  open  spaces  filled  with  blood,  and 
resembling  more  or  less  in  character  the  intervillous  spaces  of  the 

placenta.  The  syncytioma  malignum, 
in  other  words,  represents  to  a  certain 
extent  an  atypical  imitation  of  normal 
placental  tissue.  There  are  sometimes 
present  whole  chorionic  villi,  but  all 
the  tumour  cells  and  structures  always 
deviate  from  the  normal  placental  type 
by  marked  anaplastic  features. 

The  causes  of  this  disease  are  ob- 
scure. It  is  a  suggestive  fact,  however, 
that  of  the  15  cases  tabulated  by  Mar- 
chand,  12  gave  clear  histories  of  previ- 
ous "mole"  pregnancy.  Macnaughton 
Jones  states  that  hydatidiform  mole 
has  been  observed  in  45  per  cent  of  the 
cases.  The  conclusion  is,  therefore, 
forced  upon  us  that  this  form  of  intrauterine  infection  predisposes  to 
the  disease,  which  conclusion  may  further  prove  suggestive  in  regard 
to  the  general  bacterial  or  parasitic  origin  of  malignant  diseases.  Be- 
yond this  suggestive  fact,  the  etiology  of  malignant  degeneration  of  the 
decidual  structures  is  shrouded  in  as  deep  a  mystery  as  that  of  other 
malignant  diseases. 

The  symptoms  of  syncytioma  malignum  can  not  be  said  to  be  pa- 
thognomonic. The  most  significant  symptom  is  severe,  intermittent 
hemorrhage,  following  labour  or  abortion.  This  may  occur  imme- 
diately after  the  uterus  has  been  emptied;  or  it  ma}^  be  delayed  for 
some  time,  in  which  case  its  onset  will  be  attended  by  the  discharge 
of  an  hydatid  mole.  After  the  hemorrhage  ceases,  a  foul-smelling 
dirty-coloured  watery  discharge  generally  ensues.  Pain  may  or  may 
not  be  present;  but  when  it  does  exist,  it  is  frequently  provoked  by 
efforts  of  the  uterus  to  expel  clots.  The  patient  is  generally  cachectic, 
loses  flesh  rapidly,  and  speedily  shows  signs  of  advanced  ansemia. 
Exploration  of  the  pelvis  will  reveal  a  uterus  more  or  less  enlarged, 
even  beyond  what  might  be  expected  under  ordinary  circumstances  at 
the  same  period  following  delivery.  The  cervix  is  generally  found 
open,  although  this  is  far  from  a  constant  condition.  Digital  explora- 
tion of  the  uterine  cavity  will  reveal  coagula  beneath  which  are  found 
soft  vegetating  masses.  Cazin  calls  attention  to  the  fact  that  the 
neoplastic  products  are  frequently  of  such  consistence  that  they  may 
easily  be  mistaken  for  clots.  The  enlarged  uterine  wall  is  oedematous 
and  nonresistant,  and  may,  therefore,  be  perforated  with  facility  in 
the  course  of  examination. 

The  diagnosis  of  syncytioma  must  depend,  so  far  as  the  clinical 
features    of   the    case    are    concerned,    largely   upon    the    history    of 


NEOPLASMS  OF  THE  UTERUS  429 

pregnancy  followed  by  parturition  at  term  or  by  abortion;  or,  par- 
ticularly, the  history  of  hydatid  mole.  Due  attention  should  be  given 
to  the  symptomatology  just  recorded;  the  exact  character  of  the  genera- 
tive process,  however,  can  be  determined  only  by  microscopic  examina- 
tion of  some  of  the  tissue.  This  may  be  easily  removed  in  some  cases 
by  the  finger,  in  others  by  the  curette.  Another  diagnostic  sign  of 
importance  in  cases  of  longer  standing  is  the  occurrence  of  metastases. 
These  migrations,  in  consequence  of  the  special  tendency  of  this  dis- 
ease to  invade  the  blood  vessels,  are  manifested  at  an  earlier  stage  than 
in  other  malignant  diseases  of  the  uterus. 

The  treatment  must  consist  of  nothing  short  of  the  complete  removal 
of  the  uterus  and  adnexa.  (See  Vaginal  Hysterectomy.)  This  should 
be  done  as  quickly  as  the  diagnosis  can  be  made.  It  should  be  remem- 
bered, however,  that  metastases  occur  very  early  in  the  history  of  these 
cases,  and  that,  if  their  existence  is  detected,  the  operation  offers  the 
patient  no  hope  and  is,  therefore,  unjustifiable.  Roger  Williams  tabu- 
lated 14  cases  of  this  disease  that  had  been  treated  by  vaginal  hysterec- 
tomy; of  these,  12  recovered  from  the  operation,  while  2  died;  of  the 
12  primary  recoveries,  5  died  with  recurrence  within  the  first  year; 
6  of  the  remaining  7  were  free  from  recurrence  ten,  nine,  seven,  seven, 
five  and  one  half,  and  three  months,  respectively,  after  the  operation; 
nothing  was  said  of  the  after-condition  of  the  other  patient. 

Adenoma  uteri,  otherwise  designated  adenoma  malignum,  or  ade- 
noma malignum  carcinomatosum  uteri,  is  a  malignant  degeneration  of 
the  endometrium  possessing  individual  characteristics  but  having  a 
tendency  to  assume  the  carcinomatous  type. 

To  Matthews  Duncan  probably  belongs  the  distinction  of  first 
having  directed  attention  to  this  disease,  although  at  the  time  of  his 
first  report  its  histogenetic  character  was  not  recognised.  Breisky 
and  Eppinger  reported  undoubted  cases  in  1877,  at  which  date  the  real 
literature  of  the  subject  commences.  Veit  was  the  first  to  demonstrate 
that  what  appeared  primarily  to  be  simple,  benignant  adenoma,  might 
become  a  veritable  adeno-carcinoma  possessing  all  the  characters  of 
malignancy.  In  America,  Thomas  and  Groodell  were  among  the  first 
to  report  cases  of  'apparent  malignant  adenoma,  while  Mann  was  among 
the  first  to  give  a  clear  elucidation  of  the  disease.  Coe's  contributions 
to  the  subject  have  been  of  great  value. 

This  neoplasm  is  looked  upon  by  Herzog  as  probably  not  different 
from  a  carcinoma  of  a  more  common  type,  although  it  shows  such 
characteristic  histologic  features  that  it  is  now  generally  classified 
separately.  Glandular  hypertrophy  of  the  uterine  mucous  membrane 
may  reach  a  very  high  degree,  so  that  one  might  feel  inclined  to  speak 
of  it  as  an  adenoma;  and  it  has  been  asserted  that  such  extensive 
glandular  hypertrophies  have  a  tendency  to  change  into  an  adenoma 
malignum.  Yet  tbis  assertion  so  far  lacks  proof.  Typical  adenoma 
malignum  of  the  uterus,  as  shown  in  Oliver's  case  (Fig.  182),  does  not, 
as  a  rule,  present  a  well-circii inscribed  tumour,  but  a  general  diffuse 


430 


A  TEXT-BOOK  OF  GYNECOLOGY 


thickening  of  the  mucous  membrane  which  has  an  irregular,  juicy, 
velvety  appearance.  The  uterus  is  generally  moderately  enlarged  in 
all  its  dimensions.  In  very  high  degrees  of  glandular  hypertrophy,  we 
find  the  uterine  glands  often  quite  tortuous,  divided  twofold  or  threefold 

and  invaginated  upon 
themselves.  In  adenoma 
malignum  the  picture 
becomes  still  more  com- 
plicated. The  rapid  pro- 
liferation of  the  glan- 
dular epitheliimi  leads 
to  one  of  two  conditions. 
Either  the  newly  formed 
epithelia  grow  toward 
the  lumen  of  the  gland, 
and  in  their  growth 
carry  inward  toward  the 
glandular  axis  the  base- 
ment membrane,  ade- 
noma malignum  inver- 
tens  (Fig.  183);  or  they 
grow  outward,  away 
from  the  axis,  and  then 
an  adenoma  malignum 
evertens  is  formed.  Of 
course  these  two  types 
may  be  more  or  less  com- 
bined. It  is  not  easy  to 
form  a  clear  conception 
of  the  microscopic  pic- 
ture of  these  tumours 
even  from  a  very  minute 
description.  Gebhard 

(PatJiologisclie  Anatomie 
der  W6ihliche  Sexualor- 
gane,  1899),  describing 
them  in  detail,  states  that  nobody,  even  after  studying  a  full  description, 
should  imagine  himself  able  to  distinguish  every  adenoma  malignum 
from  a  glandular  hypertrophy.  Only  a  good  deal  of  microscopical  ex- 
perience can  give  safety  in  this  respect.  Herzog,  who  has  examined  sev- 
eral cases  of  adenoma  malignum,  saw  one  among  them  operated  on  by 
Henrotin  which  showed  a  very  interesting  histologic  combination.  The 
uterine  mucosa  showed  the  typical  picture  of  an  adenoma  malignum, 
except  in  those  parts  where  the  tumour  had  extended  into  the  cervix. 
Here  were  found  regular  solid  alveolar  cell  nests,  and  it  appeared  that 
the  epithelia  were  squamous  in  character.  Herzog  believes  that  there 
existed  primarily  an  adenoma  malignum  of  the  corporeal  mucosa.    The 


Fig.  182. — "  Typical  adenoma  malignum  of  the  uterus 
as  shown  in  Oliver's  case." — Herzog  (page  429). 


NEOPLASMS  OF  THE   UTERUS 


431 


malignant  process  secondarily  infected  the  cervical  mucosa  where  it 
localized  itself  in  squamous  epithelia  present  there,  either  by  a  process 
of  metaplasia  or  by  one  of  substitution. 

The  symptoms  of  adenoma  uteri  are  not  clearly  defined,  none  of 
them  being  characteristic  of  the  disease.  The  first  fact  of  importance 
is  the  relative  chronicity,  adenoma  being  the  least  active  of  the  various 
malignant  degenerations  of 
the  uterus.  The  patient  will, 
therefore,  give  a  history  cov- 
ering a  longer  period  of  time 
than  would  be  the  case  if  she 
were  afflicted  with  carci- 
noma. Coe  maintains  that 
there  is  less  pain,  that  the 
hemorrhages  are  less  fre- 
quent and  less  profuse,  and 
that  the  intervening  watery 
discharges  are  less  offensive, 
than  in  carcinoma.  The  dis- 
ease is  not  prone  to  metasta- 
tic manifestations,  which  oc- 
cur late,  if  at  all.  They  were 
entirely  absent  in  four  of 
Coe's  cases.  The  diagnosis 
depends  upon  the  symptoma- 
tology above  indicated,  and 

upon  the  detection  of  papillomatous  growths  in  the  interior  of  the 
uterus.  If  uterine  scrapings  are  examined  by  the  microscope  the  result 
is  likely  to  be  negative,  which  would  not  be  true  if  the  disease  were  car- 
cinomatous. Adenoma  is  an  insidious  disease  that  runs  a  slow  course  of 
invincible  malignancy.  It  is  important  that  the  relative  good  health 
sustained  through  a  long  period  by  patients  with  this  disease,  should 
not  be  construed  as  an  evidence  of  even  a  tendency  to  recovery.  The 
profuse  hemorrhages,  the  intervening  discharges,  the  pain  and  tender- 
ness, may  disappear  for  a  time,  only  to  return  a  little  later  with  added 
violence. 

The  treatment,  to  be  on  the  side  of  safety,  should  be  arranged  with- 
out reference  to  any  remaining  pathological  question  relative  to  the  ex- 
istence, respectively,  of  benign  and  malignant  adenomata,  and  should  be 
based  upon  the  axiom  of  Coe,  viz.:  "  There  is  only  one  variety  of  true 
adenoma  of  the  corpus  uteri,  and  that  is,  both  clinically  and  anatom- 
ically, malignant."  In  no  other  way  can  a  patient  be  given  the  benefit 
of  the  doubt,  at  least,  until  the  pathologists  themselves  can  distinguish 
between  the  two  alleged  varieties,  and  can  furnish  to  the  practitioner 
the  criteria  by  which  he  can  tell  the  one  from  the  other.  Eepeated 
curetting  is  conceded  to  augment  the  malignancy  of  the  disease,  while 
the  use  of  the  galvano-cautery  is  equally  objectionable.     Complete  ex- 


FiG.  183.— "The  newly  formed  epithelia  grow  to- 
ward the  lumen  of  the  gland,  and  in  their  growth 
carry  inward  the  basement  membrane." — Hee- 
zoG  (page  430). 


432 


A  TEXT-BOOK  OF   GYNECOLOGY 


tirpation  of  the  uterus  is  the  only  means  that  offers  safety  to  the  patient. 
(See  Vaginal  Hysterectomy.)  The  tendency  to  recurrence  after  opera- 
tion is  less  in  this  than  in  other  malignant  diseases  of  the  uterus. 

Sarcoma  uteri  is  a  malignant  neoplasm  having  its  origin  in  the 
connective  tissue  of  the  uterus,  and  is  characterized  by  an  atypical  pro- 
liferation of  connective-tissue  cells  in  a  fibrous  stroma.  It  occurs 
less  frequently  than  carcinoma  of  the  uterus.  The  first  case  was  de- 
scribed by  Mayer  in  1860,  the  diagnosis  being  confirmed  by  a  micro- 
scopic examination  of  the  specimen  by  Virchow,  but  nine  cases  were 
recorded  during  the  next  eleven  years.  Since  that  time,  however, 
much  attention  has  been  given  to  the  subject,  and  the  condition  has  a 
definite  place  in  pathology  and  surgical  therapeutics. 

Sarcoma  of  the  uterus  is  not  a  disease  of  relatively  frequent  occur- 
rence. Franque  reports  only  16  sarcomata  to  301:  carcinomata  of  the 
uterus  out  of  3,366  cases  seen  during  ten  years  at  the  Wiirzburg  gyne- 
cological clinic. 

It  occurs  as  a  rule  in  middle  and  later  life,  but  there  have  also 
been  reported  some  cases  in  very  young  children.    (See  Causes.)    It  may 

develop  primarily  in  the  mucous 
membrane  or  in  the  muscular  coat. 
Its  seat  may  be  the  vaginal  portion 
of  the  cervix,  the  cervix  proper,  or 
the  body.  The  latter  is  more  fre- 
quently the  seat  of  sarcoma  than 
the  other  parts  of  the  womb.  Sar- 
coma of  the  mucous  membrane 
forms  flat,  irregular,  roundish,  or 
polyplike  masses.  In  some  cases 
the  malignant  new  growth  may 
spring  from  a  small  circumscribed 
spot  and  form  a  growth  which 
macroscopically  can  not  be  distin- 
guished from  an  ordinary  polypoid 
hypertrophy  of  the  mucous  mem- 
brane. It  is  of  practical  impor- 
tance to  keep  this  in  mind,  because 
there  are  several  examples  on  rec- 
ord where  such  harmless-looking 
polyps  were  removed,  a  micro- 
scopic examination  not  being 
made.  Shortly  after  removal,  quite 
unexpectedly,  a  rapidly  growing 
malignant  sarcoma  made  its  ap- 
pearance. Microscopic  examination  of  such  polyps  will,  of  course, 
reveal  their  nature.  Sarcomata  of  the  uterine  mucous  membrane  are  as 
a  rule  quite  soft  in  consistence  and  have  a  tendency  to  spread  rapidly. 
They  may  develop  in  the  uterine  cavity  and  even  become  pedunculated. 


Fig.  184. — "They  may  develop  in  the  uter- 
ine cavity  and  even  become  peduncu- 
lated, as  shown  in  a  case  of  Eeed's." — 
Herzog  (page  433). 


NEOPLASMS  OP   THE   UTERUS 


433 


as  shown  in  a  case  of  Eeed's  of  which  George  E.  Jones  made  a  sketch 
(Fig.  184).  They  then  infiltrate  the  nmscularis  diffusely,  and,  when  at 
the  same  time  superficial  sloughing  takes  place,  as  it  frequently  does, 
one  is  not  able  to  ascertain  definitely  whence  the  malignant  neoplasm 
originally  started.  A  peculiar  form  of  sarcoma  of  the  mucosa  is  one 
sometimes  found  arising  from  the  cervix.  These  sarcomata  are  of  a 
papuliferous  type,  and,  since  the  papilla  are  hypertrophic,  the  whole 
growth  looks  very  much  like  a  hydatid  mole.  Primary  sarcoma  of  the 
uterine  wall  generally  begins  as  multiple  nodules  or  roundish  masses. 
It  likewise  usually  rapidly  infiltrates  the  muscularis  and  the  mucosa 
and  soon  leads  to  destructive  processes  in  the  latter.  These  malignant 
connective-tissue  tumours,  when  growing  in  the  uterus,  frequently  have 
the  tendency  to  close  the  os  internum  in  a  valvelike  manner.  This  leads 
to  one  of  the  constant  objective  symptoms  of  sarcoma  of  the  uterus, 
namely,  periodical  discharges  of  an  accumulated  bloody-watery  fluid. 
Sarcoma  of  the  uterus  spreads  by  continuity  and  not  infrequently  leads 
to  a  marked  enlargement  of  the  uterus  in  all  its  dimensions.  There 
may,  however,  also  occur  a  thinning  of  the  uterine  wall  with  inversion. 
Such  a  case  has  been  reported  by  E.  Williams.  Distant  metastases 
sometimes  take  place.  Secondary  sarcomatous  degeneration  of  prima- 
rily benign  myomata  has  been  mentioned  above. 

The  histology  of  sarcoma  uteri  is  that  of  these  malignant  connective- 
tissue  tumours  in  general.  The  neoplasm  may  be  composed  of  small 
or  large  round  cells,  spindle 
cells,  and  giant  cells.  The 
tumour  cells  as  a  ru^le  take 
their  origin  from  the  adven- 
titia  of  blood  vessels,  and 
they  proliferate  diffusely  in 
an  infiltrating  manner.  A 
regular  alveolar  structure, 
like  that  of  carcinoma,  is 
rarely  found.  The  sarcoma- 
tous tissue  is  very  rich  in 
blood  vessels  and  free  hemor- 
rhages are  found.  K  is  some- 
times difficult  to  distinguish 
a  beginning  sarcoma  of  the 
mucous  membrane  from  a 
profound  endometritis  inter- 
stitial is.  The  expert,  how- 
ever, will  be  able  to  make  a 
diagnosis  from  the  finer  cyto- 
logic characteristics  of  the  neoplasm.  In  sarcoma  of  the  uterus,  the 
tumour  cells  show  marked  variation  in  size  and  shape  and  they  present 
atypical  karyokinosos,  such  as  multipolar  figures,  hyperchromatoses, 
nuclcMr  fi-agmentation,  etc.  (Fig.  185).  Ilerzog  {Transactions  of  the 
2i) 


Fig.  185. — "In  sarcoma  of  the  uterus  the  tumour 
cells  show  marked  variation  in  size  and  shape, 
and  they  present  atypical  karyokineses." — 
Herzog. 


434 


A  TEXT-BOOK  OF  GYNECOLOGY 


Chicago  PatJioIogical  Society,  vol.  iii,  1899)  has  described  a  sarcoma  of 
the  uterus  showing  a  number  of  interesting  histologic  features;  among 
them  numerous  atypical  karyokineses  and  the  presence  of  a  large 
number  of  phagocytic  cells.  These,  which  are  not  to  be  confounded 
with  leucocytes,  are  large  tissue  cells  in  the  interior  of  which  lympho- 
cytes, leucocytes,  and  red  blood  corpuscles,  intact  or  in  various  stages 
of  dissolution,  are  found. 

Secondary   degenerations   in   sarcoma   of   the   uterus   are    usually 
marked  and  appear  quite  early.     Hemorrhage  is  one  of  the  most  con- 


FiG.  186. — "  .  .  .  The  tumour,  which  was  distinetly  sarcomatous,  was  retroperitoneal,  occu- 
pied the  whole  pelvis,  and  lifted  the  uterus  quite  to  the  umbilicus." — Reed  (page  435). 


stant  occurrences  and  it  leads  to  the  destruction  of  the  neoplastic  tissue. 
Besides  such  apoplectic  destruction  we  find  fatty,  hyaline,  and  colloid 
degeneration. 

Our  knowledge  of  encloikelioma  of  the  uterus  is  still  very  meagre. 
Cases  have  been  reported  by  Amann,  Braetz,  Gebhard,  Grape,  McFar- 
land.  Pick,  and  Veit.     These  malignant  tumours,  in  their  macroscopic 


NEOPLASMS  OP  THE  UTERUS 


435 


characters,  are  similar  either  to  the  sarcomata  or  to  the  carcinomata. 
The  cases  reported  occurred  in  women  between  the  ages  of  eighteen 
and  fifty-two  years.  The  endotheliomata  take  their  origin  from  vascu- 
lar or  lymphatic  endothelial  cells,  and  are  more  or  less  alveolar  in 
structure. 

The  researches  of  Kleinschmidt  and  Kahlden  indicate  that  sarco- 
mata may  arise  from  the  connective-tissue  elements  of  the  blood  vessels 
and  lymphatics  in  the  parenchyma  of  the  uterus;  while  Virchow,  Eo- 
kitansky,  and  Schroder,  recognise  that  fibromyomata  may  undergo 
sarcomatous  degeneration.  (See  Fibromyomata.)  There  is  abundant 
evidence,  however,  that  sarcomata,  originating  in  the  parenchyma  and 
abounding  in  round  and  spindle  celled  elements,  may  possess  sufficient 
fibrous  stroma  to  give 
them  a  consistence  by 
which  they  may  be 
mistaken  for  fibro- 
mata. The  so-called 
"  recurrent  fibroids  " 
belong  to  this  class. 
Some  of  them  grow 
to  enormous  size.  A 
case  reported  by  Ott 
{Annales  de  gynecolo- 
gie  et  cV  obstetrique) 
which  had  been  op- 
erated upon  by  Le- 
bedeff,  three  years 
previously,  and  was 
followed  by  appar- 
ent cure,  developed 
a  retroperitoneal  tu- 
mour which  lifted  the 
uterus  nearly  to  the 
umbilicus.  Eeed  op- 
erated upon  a  similar 
case  (Fig.  186)  in  the 
Cincinnati  Hospital 
(1900);  the  tumour, 
whicli  was  distinct- 
ly sarcomatous,  was 
retroperitoneal,  occu- 
pied the  whole  pelvis,  and  lifted  the  uterus  quite  to  the  umbilicus. 
After  the  removal  of  the  tumour  with  the  uterus,  the  latter  seemed 
relatively  small  as  it  was  seen  perched  upon  the  mass  (Fig.  187). 

The  fiympl.om.fi  of  sarcoma  of  the  uterus  are  hemorrhage,  offen- 
sive discharge,  and  pain,  difl'oi'ing  in  no  essential  particular  from  the 
symptoms  of  carcinoma.     Pain  does  not  occur  as  a  rule  in  the  earlier 


Fig.  187. — "  After  the  removal  of  the  tumour  with  the  uterus, 
the  latter  seemed  relatively  small  as  it  was  seen  perched 
upon  the  mass." — Eeed. 


436  '         A   TEXT-BOOK  OF   GYNECOLOGY 

stages  of  the  disease,  but  is  very  constant  in  the  later  stages.  The 
uterus  is  generally  enlarged  and  if  kept  under  observation  will  be 
found  to  increase  more  raj^idly  than  in  true  carcinoma.  If  the  cervix 
is  dilated  to  a  degree  sufficient  to  permit  of  digitation  of  the  cavity,  the 
neoplasm,  if  originating  from  the  connective  tissue  of  the  endometrium, 
and  if  of  the  distinctly  round-celled  variety,  will  be  soft  and  friable.  In 
the  majority  of  cases,  it  will  be  impossible  to  distinguish  sarcoma  from 
carcinoma,  withput  a  microscopic  examination.  The  more  solid  sar- 
comata of  parenchymatous  origin  have  about  the  same  morphology  as 
fibroids,  from  which  they  are  distinguishable,  as  a  rule,  only  by  their 
more  rapid  growth;  and  even  this  point  may  be  misleading  when  a 
tumour  of  the  strictly  myomatous  type,  in  consequence  of  pressure, 
becomes  suddenly  oedematous.  In-view  of  the  fact  that  rapidly-growing 
solid  tumours  of  the  uterus  are  sometimes  distinctly  sarcomatous  from 
the  start,  and,  in  view  of  the  fact  that  those  which  are  myomatous  in 
the  beginning  may  undergo  sarcomatous  degeneration,  it  is  safer  to 
look  upon  all  of  them  as  essentially  malignant. 

The  causes  of  sarcoma  of  the  uterus  are  not  determined.  The  fact 
that  it  is  a  disease  of  the  extremes  of  life,  and  especially  of  old  age, 
would  indicate  that  age  is  a  possible  factor.  It  is  difficult  to  reconcile 
the  evidence  on  this  point.  Thus  Eoger  Williams  finds  that  instances 
have  been  reported  by  Farnsworth  at  thirteen  months,  by  Pick  at  two 
years,  by  Ahlfeld  at  three  years  and  four  months;  and  at  various  ages 
by  Hereford,  Clay,  and  Pick.  Of  73  cases,  by  Gusserow,  4  began  under 
the  age  of  twenty-nine;  5  began  from  twenty  to  thirty;  15  began  from 
thirty  to  forty;  38  began  from  forty  to  fifty;  18  began  from  fifty  to 
sixty;  3  began  above  sixt3^  Pregnancy  and  the  marital  relation  do  not 
seem  to  exercise  much  influence.  Of  Gusserow's  73  cases,  35  were  pa- 
rous women,  who,  between  them,  had  borne  fifty-one  children;  25 
of  his  cases  were  absolutely  sterile,  4  of  them  being  virgins.  There 
is  no  evidence  that  even  in  parous  women  the  traumatism  of  parturition 
bears  any  relation  to  this  disease. 

The  treatment  of  sarcoma,  like  that  of  other  malignant  diseases  of 
the  uterus,  must  consist  of  such  means  as  will  secure  its  complete  eradi- 
cation. This  can  be  accomplished  only  by  the  extirpation  of  the  uterus. 
(See  Vaginal  Hysterectomy.)  The  disease  is  one  of  the  most  malig- 
nant and  should,  therefore,  be  attacked  as  soon  as  detected.  An  at- 
tempt has  been  made  to  treat  sarcoma  of  the  uterus,  as  of  the  more 
suj)erficial  structures,  with  the  toxines  of  er3^sipelas  and  the  Bacillus 
prodigiosus.  Coley,  who  is  largely  responsible  for  the  introduction  of 
the  treatment,  calls  attention  to  the  fact  that  collapse  is  liable  to  occur 
from  too  large  a  dose,  especially  when  injected  into  a  very  vascular 
tumour,  and  that  pysemia  has  resulted  from  the  use  of  the  serum.  The 
toxines,  to  be  of  value,  must  be  prepared  from  highly  virulent  cultures 
of  the  streptococcus  of  erysipelas.  They  seem  to  act  upon  sarcoma  by 
inducing  a  rapidly  progressing  necrobiosis  with  fatty  degeneration,  to 
secure  which  the  toxines  are  to  be  injected  directly  into  the  tumour. 


NEOPLASMS   OF  THE   UTERUS  437 

This  treatment  should  never  be  employed  in  a  ease  amenable  to  opera- 
tion, while  in  one  not  amenable,  any  treatment  which  seems  to  rest  upon 
a  logical  basis  is  justifiable.  Franque  reports  that  in  16  cases  of  sar- 
coma occurring  at  the  Wiirzburg  clinic,  1  case  remained  cured  for  five 
3^ears  after  three  operations.  Another  case  was  free  from  recurrence 
after  two  years  and  4  remained  well  for  one  year.  Two  died  on  the 
table  after  operation.  These  results  are  more  satisfactory  than  those 
reported  by  Eogivue,  in  50  cases  treated  by  hysterectomy.  Of  these 
but  3  remained  cured,  33  were  known  to  have  had  a  return  of  the 
disease,  2  of  them  within  a  year  after  the  operation. 

Carcinoma  uteri  is  a  malignant  growth,  consisting  of  epithelial  cells 
embedded  in  a  stroma  of  embryonal  character,  and  of  either  congenital 
or  post-natal  origin.  It  is  an  affection  which  was  known  to  Hippoc- 
rates and  other  ancient  medical  writers.  The  uterus  is  probably  the 
most  common  seat  of  carcinoma  in  the  human  body,  although  older 
statistics  give  the  stomach  the  first  place.  However,  when  these  statis- 
tics were  compiled,  some  affections  of  the  uterus  really  carcinomatous  in 
nature,  such  as  the  so-called  papillomata  and  cauliflower  excrescences, 
were  not  counted  in  their  proper  places.  According  to  the  statistics  of 
the  Eegistrar  General,  there  died  in  England  from  cancer  between  1847 
and  1861,  87,348  persons.  Of  these,  25,633  were  males  and  61,715 
females.  About  25,000  of  the  latter  succumbed  to  cancer  of  the  uterus. 
It  is  now  asserted  that  carcinoma  in  general,  and  carcinoma  of  the 
uterus  in  particular,  is  frightfully  on  the  increase.  Park  has  recently 
attempted  to  show  the  correctness  of  this  assertion  so  far  as  one  sec- 
tion of  our  country  is  concerned.  Dlihrssen  (Die  Verhuetung  des 
G-ebarmutterkrebses,  Medicinische  Woche,  1899),  in  commenting  upon 
the  horrible  increase  of  cancer  of  the  uterus,  states  that  25,000  die 
annually  in  the  German  Empire  from  carcinoma  uteri,  or  three  times 
as  many  as  die  in  childbed  from  all  causes.  This  author  thinks  that 
only  from  10  to  30  per  cent  of  all  cases  in  Germany  are  still  amen- 
able to  operation  when  a  definite  diagnosis  is  first  made,  because  it  is, 
as  a  rule,  made  too  late.  He  therefore  recommends  that  women  be 
made  acquainted,  through  popular  writings  of  medical  men,  with  the 
dangers  of  carcinoma  of  the  womb;  further,  that  every  means  should  be 
tried  in  every  single  case  to  arrive  at  a  correct  diagnosis  early.  After 
this  is  made,  everything  possible  should  be  done  to  induce  the  patient 
to  submit  to  an  immediate  operation.  Winter  (LeJu-huch  der  Gynd- 
kologischen  Diagnostik,  Leipzig,  1897,  p.  216)  upon  this  subject  says: 
"  The  diagnosis  of  carcinoma  of  the  uterus  is  the  most  responsible  the 
physician  is  called  upon  to  make.  The  price  for  every  failure  of  diag- 
nosis, or  for  a  diagnosis  made  so  late  that  the  cancer  has  already  become 
unsuited  for  operation,  is  a  human  life.  Under  all  circumstances,  and 
with  all  means  at  our  disposal,  we  must  strive  to  diagnose  cancer  at 
the  very  first  examination.  To  wait  in  a  suspicious  case  until  destruc- 
tive properties  become  manifest,  as  was  so  frequently  done  formerly,  is 
to-day  a  most  serious  mistake." 


438  A  TEXT-BOOK  OF   GYNECOLOGY 

The  above  quotations  are  here  cited  to  impress  the  student  and 
practitioner  with  the  importance  of  the  earliest  possible  diagnosis  of 
carcinoma  of  the  uterus,  in  which  alone  lies  the  only  possible  salvation. 
After  the  very  earliest  stages,  cases  have,  as  a  rule,  become  unsuited  to 
operation  and  are  beyond  human  aid. 

Cancer  of  the  womb  is  rare  before  the  age  of  thirty,  more  common 
between  the  fortieth  and  sixtieth  years.  It  drops  again  after  sixty  years, 
but  not  so  much  on  account  of  its  real  infrequency  at  that  period,  as 
on  account  of  the  smaller  number  of  females  alive  after  that  age. 
Married  life  and  childbirth  have  an  obvious  influence  upon  the  liability 
to  carcinoma.     An  hereditary  predisposition  is  likewise  manifest. 

PatJwlogy. — Carcinoma  of  the  uterus  may  take  its  origin  froiji 
the  portio  vaginalis,  the  cervix  proper,  or  the  body  of  the  uterus. 
Carcinoma  of  the  fortio  vaginalis  is  variable  in  its  macroscopic  charac- 
ters, and  a  good  deal  in  this  respect  depends  upon  the  rapidity  and 
the  intensity  of  secondary,  retrograde,  destructive  processes.  The  cauli- 
flower excrescences,  or  polypoid  carcinomata  of  the  portio,  arise  from  the 
lips,  and  form  either  broad  bases  or  somewhat  constricted  pedunculated 
tumour  masses,  v^arying  in  size  from  a  hazelnut  to  an  apple.  The  sur- 
face of  these  neoplasms  is  never  smooth,  but  uneven  with  crevices  and 
clefts.  It  may  be  pale  and  whitish  or  of  a  pinkish  tint,  but  the  colour 
of  the  tumour  itself  is  generally  hidden  from  view  by  a  dirty,  sero- 
purulent,  bloody,  greenish  or  yellowish,  secretion.  In  another  form 
of  carcinoma  of  this  part  of  the  uterus,  we  find  a  difi'use  infiltration 
and  hardening  of  the  portio.  In  early  stages,  ulcerations  may  be  en- 
tirely absent  and  the  surface  may  be  smooth.  When  this  form  begins 
to  ulcerate  there  may  be  present  shallow  ulcers  only,  while  in  the  forms 
first  described,  the  ulcerations  usually  lead  to  great  destruction  of  the 
tissue  and  form  craterlike  cavities.  In  spreading,  carcinoma  of  the  por- 
tio vaginalis  generally  first  reaches  and  then  infiltrates  the  vaginal  walls. 
Early  spreading  into  the  cervical  mucous  membrane  is  rare.  Involve- 
ment of  the  corpus  uteri  in  primary  carcinoma  of  the  portio  is  quite 
rare.  In  their  further  growth  these  cancers  infiltrate  the  lateral  para- 
metrium. The  bladder  is,  as  a  rule,  reached  only  late,  and  then  from  the 
anterior  vault  of  the  vagina.  Involvement  of  the  rectum  is  rare.  The 
lymphatics  involved  are  those  following  the  course  of  the  iliac  vessels. 

Carcinoma  of  the  cervix  takes  its  origin  from  the  surface  or  from 
the  glandular  epithelium  of  this  part.  It  usually  begins  as  a  cir- 
cumscribed nodule  or  as  a  diffuse  infiltration,  involving  either  part 
or  the  whole  of  the  circumference  of  the  cervix.  A  very  marked  infil- 
tration formed  in  this  manner  may  then  ulcerate  and  lead  to  extensive 
loss  of  substance  and  excavation.  Or,  there  may  be  from  the  start  a 
slight  degree  of  infiltration  only,  with  early  shallow  ulcerations  and 
destruction  of  the  superficial  layers.  Spreading  goes  on  from  the 
cervix  in  the  direction  of  the  body.  It  may  have  the  form  of  a  super- 
ficial ulceration  along  the  corporeal  mucous  membrane,  or  it  may  be 
a  diffuse  or  circumscribed  lymphatic  infiltration  into  the  uterine  wall. 


NEOPLASMS   OP   THE   UTERUS  43^ 

Spreading  over  the  vaginal  mucous  membrane  rarely,  if  ever,  occurs, 
"but  later  on,  an  infiltration  of  tlie  deeper  layers  of  the  vaginal  walls  is 
common.  The  pelvic  connective  tissue  is  generally  invaded  from  the 
deepest  part  of  the  growth.  The  bladder  is  often  involved  early,  the 
rectum,  as  a  rule,  late.  Lymph-gland  involvement  is  similar  to  that 
in  carcinoma  of  the  portio. 

Carcinoma  of  the  tody  of  the  uterus  starts  from  the  corporeal  mucous 
membrane.  In  the  diffuse  form  the  whole  mucous  membrane  is  more 
or  less  involved  and,  in  places,  infiltrated  with  thicker  roundish  or 
irregular  nodules.  The  further  development  of  the  new  growth  en- 
larges the  corpus  uteri  in  all  its  dimensions  and  the  cavity  becomes 
markedly  enlarged  so  soon  as  ulcerative  processes  and  sloughing  set  in. 
Sometimes  there  may  be  only  a  circumscribed  limited  carcinomatous 
process,  while  the  major  part  of  the  mucous  membrane  is  not  involved. 
The  polyjjoid  form  of  carcinoma  of  the  body  is  rare.  When  carcinoma 
of  the  corpus  in  its  extension  reaches  the  outer  zone  of  the  body,  ad- 
hesions to  surrounding  jDarts  become  frequent,  particularly  to  the  intes- 
tines, which  may  become  perforated  by  carcinomatous  growth.  In- 
volvement of  the  bladder  and  the  rectum  occurs  late,  as  a  rule.  The 
lymph  glands  generally  first  involved  are  the  lumbar  glands  in  the 
neighbourhood  of  the  aorta.  There  may  be  in  all  forms  of  carcinoma 
of  any  part  of  the  uterus,  an  unusual  involvement  of  lymph  glands  in 
consequence  of  reversed  metastatic  transport. 

Histology. — Carcinoma  of  the  uterus  is  a  malignant  atypical  neo- 
plasm arising  from  epithelial  structures  and  showing,  as  a  rule,  the 
well-marked  alveolar  arrangement  so  characteristic  of  cancer.  Since 
we  find  two  different  kinds  of  epithelia  in  the  uterus  we  also  find  car- 
cinomata  differing  in  the  types  of  their  cells.  The  cancers  spring- 
ing from  the  portio  are  almost  invariably  squamous-celled  carcinomata. 
The  epithelfa  lining  the  portio  proliferate  rapidly,  and  infiltrate  the 
underlying  connective  tissue  in  the  form  of  pegs  or  columns  or  pillars 
of  cells.  These  cells  in  proliferating  vary  a  good  deal  in  shape,  and 
deviate  from  the  type  from  which  they  originally  sprang.  In  the 
cervix  where  we  normally  have  no  squamous,  but  only  cylindrical 
cells,  we  likewise  find  besides  columnar-celled  cancers,  squamous 
epithelial  carcinomata.  This  is  probably  not  so  much  due  as  some 
believe  to  a  preceding  or  coinciding  metaplasia  of  the  epithelia,  as  to  a 
preceding  substitution  by  which  the  columnar  epithelium  has  been 
replaced  by  that  of  a  squamous  type  (Fig.  188).  Carcinoma  of  the  cor- 
pus consists,  as  a  rule,  of  epithelia  of  the  columnar  type.  But  it  must 
be  kept  in  mind,  that  as  soon  as  we  have  a  well-developed  alveolar 
arrangement  in  the  neoplasm,  the  epithelia  have  become  so  atypical 
in  shape  and  size  that  one  can  speak  with  propriety,  neither  of  colum- 
nar nor  of  squamous  cells;  the  latter  under  these  considerations  also 
lose  thfir  prickles. 

It  is  very  difficult  to  distinguish  between  glandular  hypertrophy 
and  beginning  carcinoma.     Eecourse  must  be  had  to  atypical  mitotic 


440 


A  TEXT-BOOK  OF   GYNECOLOGY 


figures  which  always  speak  strongly  for  tumour  formation.  These 
features  have  been  more  fully  mentioned  above  under  the  head  of  Sar- 
coma Uteri.  Amann  {Mikroskopische  Gynakologisclie  Diagnose,  Wies- 
baden, 1897)  attaches  a  good  deal  of  significance  to  the  direction  of  the 
polar  spindle  with  reference  to  the  surface  on  which  the  epithelia  are 

situated,  in  the  matter  of 
diagnosis  between  simple  hy- 
pertrophy or  malignant  neo- 
plasm. It  is  impossible  here 
to  go  into  the  finer  details  of 
the  microscopic  diagnosis  of 
carcinoma.  In  a  well-devel- 
oped case,  when  it  is,  how- 
ever, usually  too  late  to  op- 
erate, the  histologic  picture 
is  so  typical  that  even  a  tyro 
can  make  a  microscopic  diag- 
nosis. While,  on  the  other 
hand,  in  the  very  beginning, 
when  there  is  still  time  for 
a  hopeful  operation,  it  often 
requires  delicate  fixation,  ex- 
act orientation,  and  general 
careful  preparation  of  the 
microscopical  material,  to 
enable  even  the  expert  to  arrive  at  a  definite  conclusion.  In  trying  to 
get  at  the  latter  it  is  perhaps  better,  as  stated  by  Herzog  in  a  paper  on 
The  Microscopic  Diagnosis  of  Uterine  Scrapings,  to  err  on  the  side  of 
too  great  a  readiness  to  see  atypical  and  malignant  features,  instead  of 
being  too  ready  and  prone  to  overlook  the  former  and  to  se^  only  hyper- 
plastic processes;  particularly,  since  the  suspected  cases,  as  a  rule,  with 
few  exceptions,  occur  in  women  at  a  period  when  the  uterus  has  ac- 
complished its  object  as  a  fruit  bearer,  and  when  its  removal  is  not 
objectionable  from  physiological  and  social  reasons. 

The  causes  of  carcinoma  of  the  uterus  are  by  no  means  determined. 
The  disease  is  liable  to  occur  at  any  age.  Pozzi  mentions  a  case  by 
Ganghoffer,  of  a  child  nine  years  old,  who  died  from  medullary  carci- 
noma. Gusserow  accumulated  the  records  of  3,385  cases  showing  the 
age  at  which  carcinomatous  diseases  began,  as  follows: 


Fig.  188. — "The  columnar  epithelium  has  been 
replaced  by  that  of  a  squamous  type." — Heezog 
(page  439). 


17  years 1  case  (Glatter). 

19  years 1     "     (Beigel). 

20  to  30  years .. .   114  cases. 
30  to  40  years...   770      " 


40  to  50  years 1,196  cases. 

50  to  60  years 856     " 

60  to  70  years 340      " 

Above  70  years 193      " 


Pozzi  maintains  that  poverty  is  a  predisposing  cause  of  carcinoma, 
and  supports  his  contention  by  the  statistics  of  Schroder,  showing  that 
the  disease  is  1.5  per  cent  more  frequent  in  the  charity  wards  of  the 


NEOPLASMS  OF  THE  UTERUS  441 

hospitals  than  in  private  practice.  These  statistics  are  sustained  by 
the  observations  of  A.  Martin.  Dlihrssen^  on  the  other  hand,  quotes 
Eoger  Williams  approvingly  to  the  effect  that  uterine  cancer  is  not, 
as  was  believed,  more  frequent  in  the  lower  classes,  but  that  predis- 
position to  this  disease  is  given  by  the  over-feeding  and  comfortable 
position  of  those  in  better  circumstances.  Duhrssen  further  asserts 
that  more  women  die  annually  in  Germany  from  carcinoma  than  there 
were  soldiers  killed  in  the  entire  Franco-Prussian  War,  the  mortality 
ranging  from  0.5  to  1.0  per  thousand;  and  that  all  classes  alike  are 
susceptible  to  the  disease.  The  traumatisms  of  parturition  have  been 
looked  upon  as  causes  of  carcinoma  of  the  uterus;  while  the  frequent 
observation  of  commencing  cancer  at  the  site  of  an  old  laceration,  and 
the  well-known  tendency  of  cicatricial  tissue  to  undergo  malignant 
degeneration,  have  been  quoted  in  support  of  the  theory.  Statistical 
tables  bearing  upon  this  point  are  valueless,  in  view  of  the  fact  that 
the  majority  of  women  are  married  and  have  children,  and  of  the 
additional  fact  that  individual  cases  are  constantly  occurring  in  unmar- 
ried and  continent  women. 

The  question  of  the  parasitic  origin  of  carcinoma  of  the  uterus  in- 
volves the  question  of  the  germ  origin  of  carcinomata  in  general. 
Edmund  Andrews  has  conducted  a  series  of  investigations  touching 
this  point  from  which  he  concludes  that,  other  things  being  equal, 
primary  carcinoma  is  most  frequent  on  those  surfaces  which,  by  their 
position,  would  be  most  accessible  to  free  swimming  microbes  or  spores 
derived  from  without  the  body;  that  the  liability  to  cancer  is  increased 
if  the  epithelial  surface  is  so  situated  that  the  spores  can  remain  upon 
it  for  at  least  some  hours  without  being  washed  away;  and  that  the 
liability  to  cancer  is  great  if  the  membrane  has  vast  numbers  of  deep 
glandular  follicles  into  which  the  spores  can  penetrate,  and  lie  free 
from  disturbance,  and  gain  direct  access  to  the  more  delicate  epithelial 
cells.  He  has  made  an  interesting  computation  showing  the  liability 
of  different  surfaces  to  carcinoma  in  proportion  to  their  exposure  to 
germs  and  their  ability  to  afford  to  them  an  undisturbed  lodging,  by 
which  he  arrives  at  the  conclusion  that  the  cervix  uteri  is  5,776  times 
more  liable  to  cancerous  disease,  than  is  a  similar  area  of  intestine, 
which  he  computes  at  unity  and  uses  as  a  standard  for  comparison.  It 
is  interesting  to  note  that  the  vagina  is  as  61  to  1  and  the  vulva  as  364  to 
1  in  the  same  scale.  A  number  of  culture  and  inoculation  experiments 
have  been  made  with  reference  to  demonstrating  the  bacterial  origin 
of  carcinoma.  Francke  {Muncliener  medicinisclie  WochenscJirift)  be- 
lieved that  he  had  confirmed  the  alleged  discovery  by  Scheurlen  of  a 
bacillus  of  carcinoma.  This  bacillus  was  described  as  being  2  micro- 
millimetres  long  and  0.4  micromillimetres  broad,  and  as  producing 
in  culture  media  a  reddish-brown  pigment.  Subsequent  investigation, 
however,  failed  to  substantiate  the  claims  of  this  bacillus  to  recognition 
as  the  essential  organism  of  carcinoma.  While  this  organism  has  not 
been  isolated,  evidence  points  in  the  direction  of  a  bacterial  origin  of 


442  A  TEXT-BOOK  OP  GYNECOLOGY 

this  disease.  Hanan  (Fortschritte  der  Medizin)  transferred  small  por- 
tions of  the  secondary  growth  in  the  inguinal  and  axillary  glands  of  a 
white  rat,  dead  from  carcinoma  of  the  vulva,  to  the  abdominal  cavities 
of  two  other  rats;  one  of  these  animals  died  at  the  end  of  two  months, 
and  there  were  found  in  its  omentum  fully  developed  nodules  rich  in 
the  cellular  elements  of  carcinoma;  while  in  the  other  animal  there 
were  evidences  of  a  successful  vaccination  of  carcinoma.  The  repetition 
of  these  and  similar  experiments,  especially  by  Italian  investigators,  has 
confirmed  the  inoculability  of  carcinoma,  although  the  precise  ele- 
ment upon  which  this  inoculability  depends  has  not  yet  been  deter- 
mined. The  most  that  can  be  concluded  at  present  is,  that  the  evi- 
dence points  in  the  direction  of  the  bacterial  origin  of  carcinoma.  The 
investigations  now  in  progress  under  the  supervision  of  Eoswell  Park 
bid  fair  to  result  in  more  definite  conclusions. 

The  symptoms  of  carcinoma  of  the  uterus  are  uncertain  and  indefi- 
nite in  the  earlier  stages,  the  disease  in  the  majority  of  instances  being 
exceedingly  insidious  in  its  onset.  Pain  is  rarely  present  until  after 
the  disease  has  made  considerable  j^rogress.  When  it  is  located  in 
the  cervix,  the  first  symptom  to  arrest  the  attention  of  the  patient  will 
be  a  persistent  watery  discharge  slightly  tinged  with  blood;  this  may 
or  may  not  be  associated  with  foetor.  A  little  later,  the  discharge  be- 
comes distinctly  sanguineous,  and,  as  the  disease  progresses,  irregular 
and  violent  hemorrhages  occur.  The  uterus  by  this  time  generally 
becomes  more  or  less  painful — particularly  if  the  endometrium  is  in- 
volved, or  if  there  is  an  upward  extension  of  the  disease  from  the  cervix. 
The  occurrence  of  hemorrhage  at  the  menopause,  or  following  it, 
should  be  regarded  with  suspicion,  and  should  always  be  the  occasion 
for  a  careful  local  exploration.  The  diagnosis  is  generally  obvious  in 
cases  of  carcinoma  involving  the  cervix.  The  finger  will  at  once  detect 
an  enlargement  of  that  segment  of  the  womb;  if  in  the  earlier  stages, 
the  tissues  will  seem  nodular  and  indurated;  if  in  the  later  stages,  after 
disintegration  sets  in,  the  surface  will  be  irregularly  granular  and 
friable,  bleeding  upon  the  slightest  touch.  At  this  stage,  to  the  experi- 
enced surgeon,  the  odour  of  the  discharges  is  so  characteristic  that  a 
diagnosis  is  made,  as  a  rule,  before  the  examination  is  begun.  In  cases 
of  carcinoma  involving  the  corpus  uteri,  diagnosis  will  be  based,  first, 
upon  their  rarity,  and,  next,  upon  the  microscopic  examination  of  some 
of  the  tissue  removed.  In  all  cases  of  suspected  cancer  of  the  uterus, 
when  the  disease  is  not  so  advanced  that  the  diagnosis  practically  de- 
clares itself,  a  microscopic  examination  should  be  made  of  a  piece  of 
tissue  removed  from  the  diseased  area.  This  is  especially  true  when 
the  disease  is  in  its  incipiency,  manifesting  itself  by  either  an  indurated 
nodule  or  a  circumscribed  erosion  of  the  cervix.  It  is  not  important, 
from  a  practical  point  of  view,  to  distinguish  between  carcinoma  and 
sarcoma  of  the  uterus,  as  the  treatment  is  precisely  the  same  in  either 
case.  As  a  matter  of  scientific  interest,  however,  the  investigations  of 
Adamkiewicz  {C entraTblatt  filr  die  medicinisclien  WissenschafUn,  Berlin) 


NEOPLASMS  OF   THE   UTERUS 


443 


are  worthy  of  attention.  He  has  endeavoured  to  establish  distinctions 
between  carcinoma  and  sarcoma  by  inoculation  experiments.  If  fresh 
carcinoma  tissue  is  implanted  in  the  brain  of  an  animal — preferably  a 
rabbit — the  animal  will  die  in  the  course  of  two  or  three  days,  with 
severe  lesions  only  to  be  explained  by  migration  of  the  elements  of  the 
implanted  carcinoma  tissue  into  the  interstices  of  the  brain  substance, 
and  subsequent  production  of  patches  of  inflammation  and  necrosis. 
Carcinoma  tissue  also  responds  with  a  typical  reaction  to  "  cancroin,'^ 
the  trimethylvinylammoniumoxydhydrate  base  of  neurine,  the  specific 
poison  which  kills  the  carcinoma  coccidium.  Adamkiewicz  therefore 
suggests  as  an  infallible  means  of  distinguishing  carcinoma  to  implant 
a  scrap  of  the  suspected  tissue  in  a  rabbit's  brain.  If  it  is  not  carci- 
noma, the  tissue  will  be  absorbed  and  the  animal  will  remain  in  its  usual 
health.  This  and  the  absence  of  the  cancroin  reaction  indicate  a  non- 
carcinomatous  character  for  the  neoplasm. 

There  are  many  complications  of  cancer  of  the  uterus.  Carci- 
noma may  occur  in  a  myomatous  uterus;  while  myomata  themselves 
are  liable  to  undergo  malignant  degeneration — especially  of  the  sar- 
comatous type.  The  coexist- 
ence of  various  benign  and  ma- 
lignant neoplasms  in  the  same 
uterus,  while  not  frequent,  is 
occasionally  encountered.  The 
coexistence  of  sarcoma,  carci- 
noma, myoma,  and  polypus,  is 
reported  by  Keibergal  {Archiv 
fib-  Gynakologie,  1896)  (Fig. 
189).  In  cases  in  which  car- 
cinoma or  other  malignant 
neoplasms  have  begun  to  dis- 
integrate, mixed  infections  of 
the  endometrium  speedily 
ensue. 

Pregnancy   as   a   complica- 
tion of  carcinoma  of  the  uterus 
is     occasionally     encountered. 
It  is  always  a  serious  compli- 
cation, and  one  that  is  a  men- 
ace  alike   to   the   life   of   the 
foetus  and  of  the  mother.     An 
interesting  series  of  one  hun- 
dred   and    sixty-six    cases    of 
cancer   of   the   uterus,    occur- 
ring between  1886  and  1895,  has  been  compiled  by  George  H.  Noble, 
of  y\tlanta,  Ca.     The  complication  is  one  which  precludes  the  pos- 
sibility of  normal  delivery,  even  should  pregnancy  go  to  term,  while 
aboi-tion  is  likely  to  prove  fatal.     Eeed  has  reported  {Transactions  of 


Fig.  189. — "  The  coexistence  of  sarcoma,  carci- 
noma, myoma,  and  polypus  is  reported  hy 
Neiberffal." — Keed. 


444  A  TEXT-BOOK  OF   GYNECOLOGY 

the  Ohio  State  Medical  Society)  a  case  in  which  amputation  of  the  cervix 
for  carcinoma  had  been  done  by  another  operator  in  the  presence  of 
unsuspected  pregnancy,  and  in  which  the  patient  was  permitted  to  go 
to  term;  when  labour  began,  the  cervix  was  found  to  be  distinctly  car- 
cinomatous— a  condition  which,  in  the  absence  of  necessary  surgical  aid,, 
speedily  resulted  in  the  death  of  both  mother  and  child.  When  the 
cancerous  uterus  is  found  to  be  impregnated,  vaginal  hysterectomy 
should  be  done  in  the  earlier  stages  of  the  pregnancy;  or,  if  the  woman 
is  permitted  to  go  to  term,  she  should  be  delivered  by  Csesarean  sec- 
tion or  the  Porro  operation.  Vaginal  hysterectomy  should  be  em- 
ployed so  long  as  there  is  a  reasonable  opportunity  of  delivering  the 
diseased  and  impregnated  organ  by  that  route;  the  Porro  operation 
(abdominal  hysterectomy)  should  be  done  in  the  later  stages  of  preg- 
nancy, when  there  is  a  prospect  of  removing  all  of  the  malignant  struc- 
tures; the  conservative  Cesarean  operation,  according  to  Noble, 
"  ought  to  be  emjjloyed  in  all  cases  with  obstruction  to  the  birth  of  the 
child  by  extensive  exudate,  or  where  there  is  not  a  reasonable  hope  of 
eradicating  malignancy."  The  question  of  operative  interference 
after  the  period  of  viability  has  been  reached,  is  one  which  can  not  be 
settled  by  any  definite  criteria.  The  condition  ought  to  be  explained 
to  the  family  and  especially  to  the  patient,  who  should  be  given  an 
opportunity  to  choose  between  the  desperate  alternatives.  The  fact 
should  be  remembered,  that  a  carcinomatous  uterus  may  be  able  to 
carry  a  pregnancy  to  term,  and  that  a  living  child  may  be  born  by 
either  the  Ceesarean  or  the  Porro  operations.  At  the  same  time,  it 
should  be  clearly  held  in  mind  that,  in  consequence  of  a  pregnancy,  a 
carcinomatous  uterus  may  be  suddenly  provoked  to  violent  and  fatal 
hemorrhage.  The  time  for  operation,  and  the  character  of  the  opera- 
tion, should  be  determined  by  the  surgeon  and  the  patient  in  full 
recognition  of  these  facts. 

The  prognosis  of  carcinoma  if  left  to  itself  is  that  of  inevitable  fatal- 
ity. The  average  duration  of  life  when  the  disease  follows  a  natural 
course  is  from  twelve  to  eighteen  months.  In  cases  in  which  disease 
is  too  advanced  for  radical  operation,  the  conservative  treatment  by 
curettement  stops  hemorrhage  and  waste,  and  prolongs  life,  but,  of 
course,  only  defers  for  a  time  the  inevitable  termination. 

Treatment:  Palliative. — Topical  Medication. — A  quarter  of  a  cen- 
tury ago,  when  the  microscope  was  not  in  extensive  use,  cases  of 
ulceration  of  the  cervix,  one  centimetre  or  more  in  diameter,  were 
encountered,  which  were  looked  upon  as  ulcers,  chancres,  or  begin- 
ning cancers.  It  was  the  custom  to  treat  such  cases  with  lunar 
caustic,  nitric  acid,  etc.,  making  an  application  once  in  four  or  five 
days.  Carstens  has  observed  eases  in  which  this  treatment  has  been 
followed  by  perfect  healing,  though  the  disease  was  certainly  not 
syphilitic.  Hence  the  condition  must  have  been  benign  or  the  be- 
ginning of  a  malignant  growth.  On  the  contrary,  in  some  cases 
thus  treated  the  patients  were  apparently  cured  but  died  a  year  or 


NEOPLASMS  OF  THE  UTERUS  445 

two  later  of  cancer.  It  may  be  possible  that  those  patients  that  re- 
covered permanently  had  a  nonmalignant  ulcer;  while  those  who 
developed  cancer  in  a  year  or  two  had  ulcers  that  were  cancerous 
in  the  first  place,  but,  by  the  application  of  caustic,  the  removal  of 
the  neoplastic  formation,  and  the  stimulation  of  healthy  granulation, 
the  parts  healed,  although  in  the  deeper  structures  cancer  cells  re- 
mained, which  continued  to  develop  and  involve  the  whole  womb  and 
the  surrounding  structures.  In  more  advanced  cases  the  cervix  was 
removed  and  then  cauterized  with  chromic  acid,  pure  bromine,  mercuric 
nitrate,  zinc  chloride,  etc.  The  various  pastes  and  plasters  used  even 
to-day  by  quacks  who  call  themselves  cancer  doctors,  have  long  been 
discarded.  The  basis  of  all  these  plasters  and  jaastes  has  been  either 
arsenic,  lime,  or  zinc.  Any  of  these  preparations  placed  in  quantity 
on  soft  tissues  will  destroy  them  in  various  directions  and  in  a  most 
irregular  manner  that  can  not  be  controlled. 

It  was  left  to  J.  Marion  Sims  to  put  the  nonsurgical  treatment  on 
a  scientific  basis,  and  his  method  has  been  followed  with  very  slight 
modifications  ever  since  by  gynecologists.  To-day,  with  all  our  sur- 
gical experience,  we  meet  with  many  lamentable  cases  which  are  beyond 
our  surgical  skill.  All  we  can  do  is  to  relieve  symptoms,  stop  the 
hemorrhages,  prevent  the  drain  on  the  system,  ease  the  pain,  and 
prolong  life.  When  the  uterus  is  fixed  or  the  broad  ligament  involved, 
perhaps  even  the  base  of  the  bladder  or  the  vagina,  a  vaginal  hyster- 
ectomy is  of  no  use.  In  such  cases  Carstens  proceeds  as  follows:  All 
diseased  tissues  are  thoroughly  removed  with  the  knife,  scissors,  or 
sharp  curette,  going  over  the  ground  repeatedly,  so  that  the  appar- 
ently healthy  tissues  are  reached.  When  working  at  the  base  of  the 
bladder  or  rectum,  great  caution  must  be  exercised  to  prevent  per- 
foration. The  hemorrhage  may  be  extensive  at  first,  but  as  more 
healthy  tissues  are  reached,  the  hemorrhage  ceases  unless  the  circular 
or  uterine  arteries,  which  may  require  the  application  of  a  ligature 
or  the  forceps,  are  opened. 

Sims's  method  was  to  apply  iron  perchloride  to  this  large  raw  sur- 
face to  stop  the  hemorrhage,  removing  it  in  twenty-four  hours,  and 
then  applying  caustic;  but,  as  caustic  is  the  best  hemostatic,  Car- 
stens always  applies  it  at  once  as  follows:  A  piece  of  absorbent  cotton, 
of  a  size  and  shape  to  suit  the  cavity  and  made  round  or  long  accord- 
ing to  indications,  is  attached  to  a  string.  This  is  dipped  in  a  solution 
of  zinc  chloride,  one  ounce,  to  half  an  ounce  of  water.  It  is  then 
squeezed  as  dry  as  possible,  care  being  taken  to  dry  the  fingers  imme- 
diately, to  prevent  damage  to  them,  or,  still  better,  to  conduct  the 
whole  operation  with  rubber  gloves.  Having  again  dried  the  cavity, 
the  cotton  is  carefully  placed  so  that  it  comes  thoroughly  in  contact 
with  all  the  raw  surface.  If  it  is  not  dry  enough,  it  will  run  down 
the  vagina  and  cause  trouble  there.  To  prevent  this  accident,  Sims 
suggested  filling  the  vagina  with  absorbent  cotton  and  saturating  it 
will]  sofJiiitn  l)iciii'l)on;il('  which  would  immediately  neutralize  the  zinc; 


446  A   TEXT-BOOK   OP   GYNECOLOGY 

but  this  method  is  improved  upon  by  Carsteus,  who  takes  a  ball  of  dry 
absorbent  cotton  large  enough  to  fill  the  vagina,  and  to  which  also  a 
string  is  attached,  and  packs  it  into  the  vagina.  The  upper  part  catches 
any  little  discharge  of  the  chloride  of  zinc,  minimizing  its  caustic 
action  and  limiting  it  to  the  upper  part  of  the  vagina.  In  the  string 
attached  to  the  cotton  containing  the  chloride  of  zinc,  one  knot  is 
tied.  In  that  attached  to  the  dr}-  cotton  two  knots  are  tied,  in 
order  to  distinguish  them  and  to  indicate  in  wiiich  order  to  remove 
them.  This  packing  is  allowed  to  remain  for  forty-eight  hours,  when 
it  is  removed  and  vaginal  douches  used.  The  slough  that  is  formed 
by  the  caustic  comes  away  in  about  ten  days,  often  in  one  large  piece, 
leaving  beneath  it  a  clean  granulating  surface,  which  rapidly  contracts, 
and  frequently  entirely  closes,  except  the  small  fistulous  opening 
tlirough  which  menstruation  can  take  place.  It  is  astonishing  how 
quickly  women  will  recover  and  gain  strength  alter  tiiis  jjroccdure; 
the  discharge  ceases,  the  appetite  improves,  and  the  patient  gains  in 
weight  twenty  or  thirty  pounds  in  three  months,  in  the  course  of 
time,  however,  recurrence  takes  place,  sometimes  within  six  months, 
sometimes  not  for  a  yi'ar  or  more.  If  the  case  is  carefully  watched,  the 
foregoing  procedure  can  be  rej)eated  at  once  on  recurrence,  and,  if 
taken  very  early,  the  small  point  where  recurrence  takes  place  can  be 
easily  curetted  and  cauterized  without  the  use  of  an  ana\sthetic.  Sec- 
ondary de])osits  in  the  pelvic  lymphatics  or  those  of  the  intestines  or 
stomach  are.  of  course,  beyond  reach. 

Bromine  is  so  volatile  and  dillicult  to  handle  that  it  alVords  no 
advantages  whatever,  and  Carstens  has  entirely  discarded  it.  Formalin 
has  been  recommended.  Calcium  carbide  was  recommended  by  the 
late  J.  II.  Ktheridge,  of  Chicago,  but  its  u.se  in  the  hands  of  others 
yields  no  more  benefit  than,  if  as  much  as.  is  derived  from  the  zinc 
chloride.  The  technique  of  the  use  of  these  various  caustics  is  the 
same  as  that  previously  given  for  the  zinc  chloride.  It  seems  that 
the  latter  remedy  is  the  best  that  can  be  used  in  such  lamentable  cases. 

Tiie  treatment  of  malignant  growths  by  serum  is  still  in  its  in- 
fancy. The  consensus  of  the  profession  seems  to  be,  thai  in  cancer 
it  is  of  no  benefit,  but  that  in  cases  of  sarcoma,  a  limited  number 
seem  to  be  benefited.  Carstens  lias  tried  it  in  quite  a  number  of 
cases  with  absolutely  no  benefit,  and  it  has  been  used  in  the  hospital 
under  his  observation  in  many  cases,  for  malignant  growths  of  dif- 
ferent kinds  and  situated  in  difTerent  parts  of  the  body,  without 
benefit.  It  has  seemed  to  him  that  in  some  cases  there  is  a  spontaneous 
cure  of  sarcoma.  He  is  sure  that  he  has  seen  a  number  of  cases  in 
which  a  disease  that  had  been  pronounced  sarcoma  by  various  physi- 
cians, has  entirely  disappeared.  But  our  knowledge  is  still  so  limited 
that  little  hope  of  benefit  from  serum  therai)y  can  be  entertained.  If 
the  future  discovers  the  microbe  of  cancer,  as  may  be  hoped,  we  may 
hope  also  that  an  antitoxine  will  be  produced  which  will  chock  the 
ravages  of  this  terrible  disease. 


NEOPLASMS  OF   THE   UTEllUS  447 

Cureltemenl,  considered  as  a  palliative  measure  in  advanced  cases, 
is  an  expedient  in  favour  with  many  operators.  With  the  patient 
under  an  aiuesthetic,  the  diseased  parts  may  he  scraped  thoroughly 
with  a  Recamier  or  otiier  sharp  curette,  with  the  Simon  scoop,  or  with 
the  Thomas  spoon-saw.  The  scraping  should  be  followed  by  daily 
vaginal  injections  with  antiseptic  solutions.  Carstens  never  practises 
this  method,  on  the  ground  that,  if  he  did,  he  might  as  well  practise 
cauterization  (see  ante),  which  he  insists  will  accomplish  more  good. 

Iliyh  amputation  of  the  cervix  is  indicated  in  cases  in  which  the 
disease  has  gone  beyond  the  uterus,  and  where  the  discharge  is  so  dis- 
agreeabk',  and  tlie  hemon-hage  so  extensive,  as  to  make  life  a  burden. 
With  the  brilliant  results  of  to-day,  achieved  by  the  complete  removal 
of  tlie  uterus,  so-called  "high  amputation"  is  practised  but  rarely, 
and  should  never  be  employed  when  the  organ  is  removable.  The 
j)atient,  under  the  influence  of  an  anaesthetic,  is  placed  on  her  back 
with  her  buttocks  on  the  edge  of  the  operating  table.  After  the  vagina 
has  been  thoroughly  cleansed,  a  retractor  is  inserted.  The  diseased 
parts  are  grasped  with  volsella  forceps  and  the  cauliflower  growth  re- 
moved with  scissors,  after  which  the  vagina  is  again  cleansed.  Then, 
with  a  two-  or  three-pronged  volsella  forceps,  the  cervix  is  seized  more 
flrmly,  an  incision  is  made  all  round  the  uterus  at  the  junction  of  the 
mucous  membrane  of  the  vagina  and  of  the  cervix;  the  vaginal  mucous 
membrane  is  next  pushed  back  with  the  fingers,  or  with  a  blunt  dissec- 
tor, for  a  quarter  of  an  inch  or  so,  and  a  conical  piece  removed  from  the 
uterus.  The  apex  of  this  cone  corresponds  to  the  uterine  canal.  The 
hemorrhage  is  quite  profuse  when  the  circular  artery  is  cut,  and  will 
require  ligation  of  the  vessel.  Sometimes  a  simple  tvidsting  of  the 
artery  will  be  sufficient,  but  this  measure  is  not  trustworthy.  The 
cavity  thus  produced  can  be  packed  with  antiseptic  gauze,  but  it  is 
better  to  treat  it  with  zinc  chloride  as  before  mentioned. 

The  radical  treatment  of  carcinoma  of  the  uterus  consists  in  the 
extirpation  of  the  diseased  organ,  and  of  the  neighbouring  lymphatic 
glands  when  they  are  involved  and  removable.  The  operation  has 
been  extended  in  recent  years  to  include  the  removal  of  lymphatic 
glands  from  the  interior  of  the  pelvis,  and  to  the  removal  of  a  part  or 
all  of  the  vagina.  The  uterus  may  be  removed  by  either  the  vaginal 
route  (vaginal  Jiysteredomij),  or  by  abdominal  section  {ahdomino- 
vaginal  panhysterectomy). 

Vaginal  Hysterectomy. — The  removal  of  the  uterus  by  the  vaginal 
route  is  not  a  new  operation,  having  been  performed  in  a  limited  num- 
ber of  cases  early  in  the  present  century  by  several  operators,  among 
whom  Osiander,  von  Langenbeck,  and  Sauter  were  prominent.  But 
the  technique  then  practised  met  with  such  indifferent  success  that  the 
procedure  was  practically  abandoned  until  the  advent  of  antiseptic  sur- 
gery and  improved  hemostasis.  Its  revival  is  due  to  the  work  of  Czerny 
in  1878,  since  which  time  it  has  by  many  operators  been  given  the  pref- 
erence in  selected  cases  over  the  abdominal  route. 


448 


A  TEXT-BOOK   OF  GYNECOLOGY 


Instruments  for  Vaginal  Hysterectomy 


Catheter,  glass 1 

Curette,  small  (Sims's  modified) 1 

Martin's 1 

Forceps,  long  dissecting  (Fig.  190) ....   1 

Sliort  dissecting 2 

Long  hemostatic 6 

Medium  hemostatic 6 

Small  hemostatic 6 

Bullet 2 

Xeedles,  curved  (Fig.  191),  large 2 

Small 3 

Medium 2 

Transfixion,  right  curved 1 

Straight 1 

Needle  holders  (Fig.  192) 2 

Museux's  Tolsella  forceps 2 

Hysterectomy  forceps,  Pean's  curved  .  2 
Pean's  straight 2 


Paclier,  vaginal  (Fig.  193) 1 

Retractors, 'large 1  pair. 

Next  size  smaller 1     " 

Small  size. 1     •' 

Scalpels 2 

Scissors,  long 1  pair. 

Sharp-pointed 1     " 

Speculum,  Jones's 1 

Sims's  medium 1 

Simon's,  with  handles  and  four 

blades 1 

Sound,  uterine 1 


Sponge  holders  (Fig.  194) 4 

Tenaculum,  Cullen's  (Fig.  195) 

Straight 

Blunt 


1 
1 
1 
Round,  sharp 1 


An  angeiotribe  or  a  Skene's  electro-hemostatic  forceps  (see  Hemo- 
stasis),  with  attachments,  should  be  at  hand  provided  the  operator  de- 
sires to  avail  himself  of  these  means  of  hemostasis. 

Technique  of  Vaginal  Hysterectomy.- — The  f)rocedure  is  as  follows: 
The  patient,  prepared  as  is  usual  for  vaginal  and  peritoneal  section,  is 
placed  in  the  lithotomy  position  with  the  hips  well  over  the  edge  of 
the  table.     The  posterior  vaginal  wall  is  retracted  by  means  of  a  Sims 

or  Alvard,  or  preferably 
a  Jones,  self-retaining 
speculum,  exposing  the 
vaginal  vault  and  cervix 
uteri.  The  anterior  lip 
of  the  cervix  is  seized 
with  the  volsella  forceps, 
and  the  uterus  drawn 
down  (Fig.  196),  continu- 
ous irrigation  with  a 
solution  of  bichloride 
(1  to  4,000)  being  em- 
ployed from  this  point 
until  the  peritoneal  cav- 
ity is  opened. 

In  septic,  and  some 
cancerous  cases,  the  cer- 
vical canal  should  be  curetted  and  swabbed  with  a  95-per-cent  solution  of 
carbolic  acid.  When  extensive  sloughing  of  the  cervix  has  occurred,  it  is 
best  to  curette  and  cauterize  it  during  the  preparatory  treatment  of  the 
preceding  week,  to  eliminate  as  much  debris  and  septic  material  as  pos- 
sible from  the  field  of  operation.    In  all  cases,  curetting  and  cauteriza- 


190. — Dissecthig  forceps. — Kobi 


NEOPLASMS   OF   THE   UTERUS 


U9 


tion  is  followed  by  sewing  together  of  the  anterior  and  posterior  lips  of 
the  OS,  effectually  closing  it  against  leakage  from  the  affected  organ. 
This  is  accomplished  by  three  or  four  interrupted  sutures  of  the  strong- 
est braided  silk,  the  ends  of  which  are  left  long  for  traction.  A  circular 
incision  is  made  through 
the  mucous  membrane  of 
the  vagina,  and  carried 
round  the  entire  cervix, 
keeping  close  to  that  or- 
gan except  in  carcinoma- 
tous cases  where  a  margin 
of  2  centimetres  (0.75 
inch)  should  be  allowed 
for  possible  cellular  inva- 
sion. The  electric  cautery 
or  the  thermo-cautery  is 
substituted  for  the  knife 
or  scissors  by  some  oper- 
ators in  making  this  dis- 
section, to  obviate  the  use 
of  catgut  or  silk  ligatures 
not  infrequently  required 
on  the  vaginal  arteries. 

ISTewman  uses  the  in- 
dex and  middle  fingers  to 
peel  up  the  layer  of  con- 
nective tissue  from  in 
front  of,  and  behind,  the 
cervix  until  the  perito- 
neum is  reached.  This  can  be  recognised  by  the  smooth  gliding  of 
its  surfaces  one  ujDon  another,  and  the  small  fluid  accumulations  in 
the  cul-de-sac  of  Douglas.  The  irrigation  of  the  vagina  is  now  dis- 
continued, and  sponging  with  gauze  substituted.  The  peritoneum  is 
seized  with  tissue  or  artery  forceps,  nicked  with  the  scissors,  and 
the  finger  thrust  through  into  the  peritoneal  cavity.  The  opening 
is  extended  with  the  fingers,  as  far  as  the  broad  ligament  upon  either 
side.  The  outer  surfaces  of  the  uterus,  its  adnexa  and  surrounding 
structures,  are  carefully  examined,  adhesions  broken  up,  and  a  gauze 
sponge  with  tape  attached,  to  which  a  catch  forceps  is  applied,  should 
be  carried  up  into  the  peritoneal  cavity  to  protect  the  parts  from 
infectious  material,  and  prevent  the  protrusion  of  omentum  and  in- 
testine. 

In  the  separation  of  the  bladder  from,  the  anterior  cervical  attach- 
ments, great  care  should  be  exercised  not  to  perforate  or  injure  this 
organ  or  the  ureters  situated  at  the  sides  and  front  of  the  wound  in  its 
lower  portion.  Accident  may  be  avoided  by  keeping  the  palmar  sur- 
face of  the  dissecting  fiugoi-s  in  close  apposition  to  the  uterine  walls. 
30 


Fig.  191. — Curved  needles. — Eobb  (page  448). 


450 


A    TEXT-BOOK   OF   GYNECOLOGY 


The  vesico-uterine  folds  of  the  peritoneal  membrane  are  opened 
close  to  their  uterine  attachment  and  the  fingers  inserted,  enlarging  the 
opening  laterally,  pushing  the  ureters  carefull}^  to  either  side,  and  com- 
pleting the  separation  of  the  bladder.  The  uterus  Avill  now  be  found 
suspended  in  the  pelvis  by  the  broad  and  round  ligaments  alone.  The 
clamping  or  ligating  of  this  vascular  area  should  be  done  with  great  care 
and  precision,  and,  in  each  instance  before  the  application  of  the  clamp 
or  ligature,  its  site  should  be  drawn  down  and  carefully  inspected. 

With  the  cervix  drawn  well  to  the  left,  and  using  lateral  retractors 
to  bring  the  structures  well  into  view,  the  base  of  the  right  broad  liga- 
ment is  seized  between  the  left  thumb  in 
front  and  index  finger  behind,  and  the 
uterine  artery  palpated.  The  portion  of  the 
ligament  containing  the  artery  is  now  in- 
cluded  in    the    bite    of   a    strong    ligament 


Fig.  192.— Keedle 
holders. — Eobb 
(page  448). 


Fig.  193.— Pack- 
er.— Kobe  (page 
448). 


Fig.  195. — Cullen's 
tenaculum. — Eobb 
(page  448). 


Fig.  194. — Sponge  holders. 
— Eobb  (page  448). 


forceps,  or  a  strong  silk  ligature  is  applied  about  a  centimetre  distant 
from  the  uterus  with  a  full  curved  aneurism  needle  (Fig.  197),  and 
tied  firmly. 

The  structures  are  now  divided  with  scissors  between  the  clamp  or 
ligature  and  the  uterus,  close  to  that  organ;  and  the  base  of  the  left 
broad  ligament,  with  the  uterine  artery  of  that  side,  is  treated  in  the 
same  way. 


NEOPLASMS   OP   THE   UTERUS 


451 


Firm  traction  brings  down  the  uterus  for  the  placing  of  a  second 
clamp  or  ligature  immediately  above  the  first  on  either  side,  and  the 
tissues  are  incised  in  the  same  manner. 

Using  the  finger  as  a  guide,  a  large  blunt  hook  or  the  finger  is  now 
passed  over  the  top  of  the  broad  ligament,  one  side  brought  do^vn  suffi- 
ciently to  permit  the  ap- 
plication of  a  third  clamp 
or  ligature,  and  the  last 
incision  is  made,  freeing 
the  uterus  entirely  from 
its  attachments  upon  that 
-side.  The  fundus  is 
drawn  down  outside  the 
vulva,  the  clamp  or  liga- 
ture easily  applied  to  the 
remaining  portion  of  the 
broad  ligament,  and  the 
uterus  cut  away. 

Many  operators  vary 
this  technique  at  the 
point  where  the  uterine 
arteries  have  been  se- 
cured by  clamp  or  for- 
ceps, and  the  base  of  the 
broad  ligament  incised, 
by  rotating  the  uterus 
forward  through  the  an- 
terior vesico-uterine  in- 
cision, or  backward 
through  the  posterior 
cul-de-sac.  As  a  rule, 
this  is  easily  accom- 
plished by  first  pushing 
the  cervix  upward  and 
forward,  or  backward,  as 
the  case  may  be,  and  then 

seizing  the  body  of  the  uterus  a  little  in  advance  of  the  cervix  with 
a  strong  volsella  forceps,  and  drawing  it  down  either  anteriorly  or  posr 
teriorly,  as  desired.  A  second  forceps  then  secures  the  tissues  a  little 
higher  up,  rotating  or  dragging  the  fundus  still  farther  downward  until 
it  can  be  grasped  and  drawn  out  completely  inverted. 

Tlic  ligation  or  clamping  of  the  ovarian  arteries  or  the  upper  por- 
tion of  the  broad  ligament,  now  proceeds  from  above  downward,  close  to 
the  uterus  if  the  ovaries  are  to  be  saved,  or  beyond  both  tubes  and  ova- 
ries along  the  tubo-infimdibular  ligament,  if  they  are  to  be  sacrificed. 

Careful  inspection  shonlfl  now  bo  made  of  the  stumps  of  the  broad 
ligament,  which  are  gently  drawn  down  for  the  purpose.     If  there  is 


Fig.  196. — ''  The  anterior  lip  of  the  cervix  is  seized  with 
the  volsella  forceps  and  the  uterus  drawn  down."' — 
Newman  (page  448). 


452 


A  TEXT-BOOK  OF  GYNECOLOGY 


% 


any  bleeding,  the  insecure  clamp  or  ligature  should  be  readjusted. 
The  vagina  is  sponged  free  of  clots,  and  the  sponge  or  sponges  removed 
from  the  peritoneal  cavity.  A  running  catgut  suture,  which  should 
include  peritoneal  and  vaginal  tissue,  closes  the  vaginal  vault,  and 
secures  the  stumps  of  the  broad  ligaments  in  either 
angle  of  the  wound. 

Full-width  gauze,  or  narrower,  with  edges 
hemmed  to  prevent  fraying,  is  used  to  pack  the 
vaginal  vault. 

Where  the  forceps  is  used  and  suturing  of  the 
vault  omitted,  particular  care  should  be  taken  to  pro- 
tect the  ends  of  the  clamps  from  projecting  upward 
and  coming  in  contact  with  the  intestines.  In  this 
case  the  gauze  packing  not  only  protects  the  ends 
of  the  forceps  and  serves  for  drainage,  but,  being 
carefully  placed  above  between  the  stumps  of  the 
broad  ligament,  prevents  hernia  or  protrusion  of  the 
intestines.  Gauze  should  also  be  so  placed  about  the 
shanks  of  the  forceps  as  to  prevent  danger  of  tissue 
necrosis  of  the  vagina  or  vulva.  The  usual  vulvar 
dressings  are  now  applied,  the  handles  of  the  forceps 
wrapped  with  gauze,  and  the  patient  put  to  bed. 
The  urine  should  be  drawn  every  six  or  eight  hours, 
and  the  external  genitals  bathed  each  time  with  1-to- 
4,000  bichloride.  The  forceps  are  removed  in  from 
36  to  48  hours,  but  the  gauze  packing  remains  undis- 
turbed for  from  24  to  48  hours  longer. 

When  the  gauze  is  removed  at  the  end  of  this 
time  the  patient  should  be  in  a  good  light  and  the 
packed  area  in  full  view,  so  that  there  may  be  no 
danger  of  disturbing  the  superimposed  intestines. 
A  careful  douching  of  the  parts  with  sterilized 
water  or  boric-acid  solution,  may  now  be  used  twice  daily,  taking  care 
not  to  carry  the  douche  point  too  high  up,  or  to  allow  too  great  force 
to  the  flow.  The  bowels  should  be  moved  by  a  laxative  pill  or  mild 
salines  followed  by  an  enema  the  second  day,  and  each  day  thereafter. 
No  straining  at  stool  should  be  allowed.  Liquid  diet  should  be  given 
for  three  or  four  days,  followed  by  nourishing  but  easily  digested  soft 
foods,  nutritious  broths,  soft-boiled  eggs,  custards,  and  the  like. 

When  the  ligatures  have  been  used  upon  the  broad  ligaments  and 
fail  to  come  away  within  a  reasonable  time  after- the  operation,  in  the 
second  or  third  week  they  should  be  gently  drawn  upon  daily,  and  if 
still  resistant,  Sims's  speculum  should  be  used,  and  the  ligatures 
removed  under  ocular  inspection  by  cutting  the  loop.  In  general,  the 
patient  may  be  allowed  to  sit  up  in  bed  at  the  beginning  of  the  third 
week,  and  at  its  end  may  be  up  in  an  easy  chair,  and  about  the  room  in 
the  fourth  week  of  convalescence. 


^ 


Fig.  197.  — "A  full 
curved  aneurism 
needle."  —  New- 
man (page  450). 


NEOPLASMS  OF  THE  UTERUS  453 

All  cancer  cases  should  be  carefully  examined  from  time  to  time 
for  recurrence  of  the  disease. 

Among  the  later  and  more  important  modifications  in  the  tech- 
nique of  vaginal  hysterectomy,  should  be  mentioned  that  of  removing 
with  the  cancerous  uterus  the  pelvic  lymphatic  glands,  a  procedure 
analogous  to  the  operation  upon  the  axillary  glands  in  mammary  carci- 
noma; the  operation  described  and  done  by  Sippel,  who  opened  into 
the  ischiorectal  cavity  by  lateral  incision  between  the  anus  and  the 
tuber  ischii,  and  removed  the  vagina  and  uterus  unopened  and  in  their 
normal  connection,  claiming  as  advantages  a  good  view,  the  accessi- 
bility of  field,  and  the  possibility  of  avoiding  any  contact  whatever 
with  carcinoma,  or  the  contents  of  the  vagina;  and  the  use  of  the 
angeiotribe,  or  pressure  clamp,  to  replace  both  retention  clamps  and 
ligatures  for  hemostasis  of  the  broad  ligament  in  vaginal  and  abdominal 
hysterectomy. 

Abdomino-vaginal  panhysterectomy  for  malignant  disease  has  been 
strongly  advocated  by  some,  where  the  uterus  could  not  be  pulled  down 
on  account  of  adhesions,  and  also  for  the  purpose  of  more  thoroughly 
removing  diseased  tissues  and  the  lymphatic  glands  situated  within  the 
broad  ligaments,  near  the  crest  of  the  ilium,  or  in  the  neighbourhood 
of  the  ureters.  There  are  exceptional  cases  in  which  this  operation 
is  required.  When  vaginal  hysterectomy  by  the  clamp  method  was 
in  its  infancy  and  only  one  clamp  was  used  on  each  broad  ligament, 
the  tissues  would  sometimes  pull  out  and  the  hemorrhage  could  not  be 
stopped,  so  that  the  abdomen  had  to  be  opened  in  order  to  control  the 
bleeding.  With  the  present  technique,  this  seldom  if  ever  occurs. 
When  the  disease  is  so  far  advanced  that  the  uterus  with  the  diseased 
tissues  can  not  be  removed  per  vaginam,  surgical  intervention  is  of  no 
avail  for  ultimate  cure,  while  the  immediate  mortality  certainly  must 
be  great.  When  metastasis  into  the  lymphatics  has  once  taken  place 
there  is  no  guarantee  that  it  can  be  overtaken.  The  experience  of 
distinguished  operators  goes  to  show  that  secondary  deposits  are  more 
liable  to  occur  in  the  stomach,  liver,  or  high  up  in  the  intestines,  than 
anywhere  else.  Hence  Carstens  would  not  advocate  abdominal  section 
in  malignant  diseases  except  in  cases  of  sarcoma  where  the  uterus  is 
very  large  and  still  movable.  There  are  others,  however,  who  assume 
that  continued  efforts  should  be  made  to  eradicate,  if  possible,  carci- 
nomatous glands  of  the  pelvis.  Although  the  operation  is  one  of  ex- 
treme severity  it  has  a  certain  justification  in  the  otherwise  hopeless 
character  of  the  disease.  It  ought  not  to  be  undertaken  without  hav- 
ing been  first  explained  to  the  patient,  who  ought  to  be  frankly  advised 
of  the  desperate  alternatives.  It  is,  to-day,  an  operation  from  which 
nothing  can  be  promised — although  something  may  be  realized. 

The  extended  operation  for  advanced  carcinoma  of  the  uterus  in- 
volves llie  rcnioval,  not  only  of  the  diseased  organ,  but  also  of  the 
infecterl  lymphatics  within  the  pelvis.  The  operation  is  graphically 
describof]   (American  Gynecological  and  Ohdelrical  Journal,  1898)  by 


454 


A   TEXT-BOOK   OF   GYNECOLOGY 


Fig.  198. — "  The  patient  is  placed  in  a  very 
steep  Trendelenburg-  position." — Eeeu. 


Emil  Keis.  The  j^atient  is  placed  in  a  very  steep  Trendelenburg  posi- 
tion (Fig.  198)  and  an  incision  is  made  from  the  pubis  to  the  umbilicus. 
The  intestines  either  sink  or  are  placed  back  toward  the  diaphragm, 
after  which  the  surgeon  inspects  and  palpates  the  pelvic  organs  and 
the  large  blood  vessels  from  the  aorta  to  Poupart's  ligament  and  to 
the  uterine  artery.  If  during  this  examination  enlarged  and  im- 
movable glands  are  found,  it  is 
advisable  to  cut  the  operation 
short  and  to  do  only  such  pallia- 
tive work  as  will  afford  as  little 
danger  to  the  patient's  life  and  as 
much  i^rotection  against  hemor- 
rhage, discharge,  and  pain,  as 
possible.  If  there  is  no  such  en- 
largement of  the  glands,  the  op- 
eration continues  as  follows: 
First,  the  right  infundibulo-pel- 
vic  ligament  is  ligated  close  to 
the  pelvic  wall;  a  clamp  covers 
the  broad  ligament  between  the 
ligature  and  the  uterus,  and  the 
ligament  is  cut  through  between 
the  ligature  and  the  clamp.  The 
peritoneum  is  now  incised  along 
the  common  iliac  vessels,  which  are  further  exposed  by  blunt  or 
sharp  dissection.  Pushing  the  peritoneum  back  toward  the  side, 
the  ureter,  which  crosses  the  common  iliac  vessels  on  or  near  their 
bifurcation,  is  soon  reached.  The  ureter  is  then  laid  bare  from  the 
brim  of  the  pelvis  down  to  its  point  of  entrance  into  the  bladder, 
with  the  aid  of  an  incision  through  the  peritoneum  of  the  vesico- 
uterine pouch.  As  this  is  done  under  the  constant  guidance  of  the 
eye  there  is  no  danger  of  injuring  the  ureter.  The  blood  vessels 
whicli  are  cut  in  this  procedure  are  ligated  or  temporarily  provided  for 
with  clamps.  The  uterine  artery  is  plainly  seen  in  this  dissection  at 
a  point  where  it  crosses  the  ureter,  and  can  easily  be  ligated  under  the 
guidance  of  the  eye  at  its  starting-point  from  the  hypogastric  artery 
outside  the  ureter.  After  the  ureter  is  thus  laid  bare  and  the  uterine  and 
ovarian  vessels  are  secured,  there  is  remarkably  little  hemorrhage  from 
the  procedure  which  follows  and  forms  the  most  important  new  step  in 
this  operation — the  removal  of  the  lymphatics  with  the  surrounding  fat 
and  connective  tissue.  This  is  done  by  dissection  with  either  a  blunt  or 
a  sharp  instrument.  The  area  which  was  cleaned  out  in  this  way 
extended  in  Eeis's  cases  over  a  surface  limited  by  the  lateral  edge  of 
the  external  iliac  vessels  superiorly,  the  pelvic  Avail  laterally,  the  blad- 
der anteriorly,  the  pelvic  floor  interiorly,  and  posteriorly  by  the  meso- 
rectum  which,  however,  was  lifted  up  and  freed  from  all  accessible 
glands.    Bleeding  vessels  are  ligated,  or  the  hemorrhage,  when  it  comes 


NEOPLASMS  OF  THE  UTERUS  455 

from  the  side  of  the  uterus,  is  checked  by  clamps,  or  simply  by  pull- 
ing hard  on  the  uterus.  Two  edges  of  the  peritoneum  remain  after 
the  whole  broad  ligament  and  all  the  fat  and  connective  tissue  along  the 
large  vessels  and  the  pelvic  wall  are  removed.  If  adhesions  exist  between 
uterus  and  rectum,  they  are  cut  as  close  to  the  rectum  as  possible,  be- 
cause they  sometimes  form  the  path  along  which  carcinoma  spreads. 

Then  the  procedure  as  done  on  the  right  side  is  repeated  on  the 
left,  special  attention  being  necessary  here  in  order  to  empty  the 
mesorectum  as  completely  as  possible  without  injuring  too  many  of 
fhe  hemorrhoidal  vessels.  The  ureter  and  uterine  artery  are  treated  in 
the  same  way;  the  removal  of  fat  and  connective  tissue  with  the  lym- 
.-phatics  being  carried  to  the  same  extent  as  on  the  other  side.  The  peri- 
toneum is  left  open  for  the  time  being,  as  on  the  other  side,  that  the 
hemorrhage  may  be  stopped  by  ligation  of  the  blood  vessels.  Small  ar- 
teries supplying  the  lymphatic  glands  sometimes  give  rise  to  some  hem- 
orrhage and  must  be  secured  by  ligatures.  The  round  ligaments  are 
•severed  close  to  the  anterior  abdominal  wall.  The  peritoneum  of  the 
cul-de-sac  is  now  incised  close  to  the  rectum  and  tbe  vagina  is  perfo- 
rated at  this  point,  either  against  the  finger  of  an  assistant,  or  against 
.gauze  introduced  into  the  vagina.  The  vagina  is  severed  after  its  walls 
have  been  secured  by  ligatures.  The  uterus  is  in  this  way  freed  all 
round  and  is  removed.  The  wound  can  be  closed  toward  the  peritoneal 
cavity  by  suturing  the  peritoneal  edges  left  in  removing  the  broad  liga- 
ments and  the  uterus.  This  suture  runs  across  the  bottom  of  the  pelvis 
in  a  transverse  direction,  uniting  laterally  the  edges  of  the  peritoneum 
■of  the  vesico-uterine  and  recto-uterine  pouches,  and  in  the  median 
line  the  peritoneum  of  the  bladder  and  the  rectum.  Before  this  part 
of  the  operation,  the  space  between  the  peritoneum  and  the  cut  edges  of 
the  vagina  is  filled  with  iodoform  gauze  if  there  is  any  oozing,  or,  if 
everything  is  perfectly  dry,  the  cut  edges  of  the  vagina  and  the  peri- 
toneum can  be  closed  in  such  way  as  to  leave  no  dead  spaces  between 
them.  The  subsequent  management  of  the  case  is  the  same  as  in 
abdomino-vaginal  section  for  benign  growths. 

Werder,  of  Pittsburg,  has  extended  the  operation  of  abdominal 
hysterectomy  for  cancer  by  removing,  in  certain  cases,  all  or  a  part  of 
the  vagina.  The  operation  is  done  as  in  an  ordinary  hysterectomy, 
only  after  freeing  the  bladder  the  dissection  is  extended  down  along 
the  vagina,  separating  its  anterior  wall  from  the  bladder  as  far  down 
as  it  is  desirable  to  remove  the  vagina;  the  recto-vaginal  space  is  then 
entered  and  the  posterior  wall  is  stripped  off  the  rectum  so  far  as  is 
necessary,  and,  finally,  the  lateral  attachments  of  the  vagina  are 
loosened.  The  uterus  is  now  pushed  down  into  the  pelvic  outlet,  the  va- 
gina being  inverted  by  making  traction  from  below  until  it  can  be  am- 
putated above  the  prolapsed  fundus.  Werder  claims  for  tliis  operation 
that  it  affords  the  best  opportunity  for  maintaining  an  aseptic  field, 
since  it  can  be  done  without  touching  the  diseased  cervix  with  the  fin- 
.gers.    Ife  has  r(;porL('d  sikh^cssI'iiI  results  from  this  rnetliod  of  operating. 


456 


A  TEXT-BOOK  OP   GYNECOLOGY 


Byrne's  Operation  of  Electro-hysterectomy. — An  operation  that 
has  occasioned  much  confusion  in  the  surgical  world  is  that  devised 
by  John  Byrne,  of  Brooklyn,  and  designated  by  him  "  high  amputa- 
tion of  the  cervix."  It  consists  in  the  removal  of  the  whole  uterus  ex- 
cept a  thin  shell  at  the  fundus  (Fig.  199)  and  is,  to  all  intents  and  pur- 
poses, a  hysterectomy,  the  uterus  being  cut  out  by  an  electric  knife, 

"  followed  by  thorough  dry 
roasting  of  the  remaining  ex- 
cavation." To  designate  it  as 
"  high  amputation  of  the  cer- 
vix "  and  to  attribute  its  re- 
sults to  "  amputation  of  the 
cervix,"  is  to  impart  the  mis- 
leading idea  that  those  results 
have  been  realized  by  the  re- 
moval of  merely  the  lower  seg- 
ment of  the  uterus.  The  title 
mistakenly  given  to  this  opera- 
tion has  itself,  and  Avithout  any 
reference  to  the  scope  of  the 
procedure,  prompted  many  not 
overstudious  operators  to  at- 
tempt the  cure  of  cancer  of  the 
cervix  by  simple  amjDutation  of 
the  neck  of  the  uterus.  The  re- 
sult has  been  a  tragic  mortality, 
much  of  which  might  have 
been  avoided;  but  which  has,  happily,  resulted  in  the  emphatic  verdict 
of  the  profession  that  the  surgical  treatment  of  cancer  of  the  uterus,  to 
be  successful,  must  involve  the  removal  of  the  entire  organ.  Of  the 
various  operations  for  the  removal  of  the  uterus,  none  are  more  effect- 
ive, and  certainly  none  are  followed  by  more  satisfactory  ultimate  re- 
sults, than  the  brilliant  procedure  of  Bryne,  as  practised  by  himself, 
and  described  (Eledro-Hemostasis,  Skene,  p.  71)  as  follows: 

"  A  diverging  volsella,  after  being  passed  well  into  the  cervical 
canal,  should  be  expanded  to  a  proper  degree  and  locked,  so  as  to 
afford  complete  control  of  the  uterus  during  the  entire  operation. 
By  alternate  traction  and  upward  pressure  of  the  uterus,  an  accurate 
idea  may  be  obtained  as  to  the  proper  point  to  begin  the  circular  in- 
cision, so  as  to  avoid  injuring  the  bladder  or  opening  into  the  cul-de- 
sac  of  Douglas.  As  to  the  latter,  however,  should  it  be  found  that  the 
disease  has  involved  the  retro-uterine  tissues,  and  that  its  excision 
or  destruction  by  the  cautery  can  not  be  effected  without  opening  into 
the  peritoneal  cavity,  there  need  be  no  hesitation  in  doing  so.  I  have 
never  known  any  harm  to  come  from  it  whether  it  was  done  acciden- 
tally or  by  design.  Should  it  be  evident  at  tlie  outset  that  the  opera- 
tion, in  order  to  be  thorough,  must  include  a  portion  of  the  cul-de-sac. 


Fig.  199. — "It  consists  in  the  removal  of  the 
whole  uterus  except  a  thin  shell  at  the  fun- 
dus."— Eeed. 


NEOPLASMS  OF  THE  UTERUS  457 

it  will  be  better  to  make  the  line  of  incision  anterior  to  this,  until  the 
cervix  has  been  removed,  and  leave  the  incision  of  the  retro-uterine 
parts  by  the  cautery  knife  to  be  the  final  proceeding.  Under  these 
circumstances  all  that  will  be  needed  will  be  an  antiseptic  tampon  prop- 
erly applied.  In  jaroceeding  to  make  the  circular  incision,  the  cautery 
knife,  slightly  curved  an,d  cold,  should  be  applied  close  up  to  the 
vaginal  junction,  and  from  the  moment  the  current  is  turned  on, 
should  be  kept  in  contact  with  the  parts  being  incised.  Before  remov- 
ing the  electrode  for  any  purpose,  such  as  change  of  position,  or  alter- 
ing the  curve  of  the  knife,  the  current  should  first  be  stopped  and  the 
instrument  again  placed  into  position  while  cool  before  resuming  the 
incision.  In  other  words,  if  the  knife,  though  heated  only  to  a  dull 
red,  be  applied  to  parts  at  all  vascular,  hemorrhage  more  or  less 
will  certainly  follow;  whereas,  the  cool  platinum  blade  being  already 
in  contact  with  moisture  as  the  current  is  being  transformed  into  heat, 
vessels  are  shrunken  or  closed  even  before  they  are  severed.  This  is  a 
very  important  point  and  should  never  be  lost  sight  of  in  all  cautery 
operations.  The  circular  incision  having  been  made  to  the  depth,  say, 
of  a  quarter  of  an  inch,  it  will  now  be  observed  that  by  increased  trac- 
tion the  uterus  may  be  drawn  much  farther  downward,  and  by  directing 
the  knife  upward  and  inward  the  amputation  may  be  carried  to  any 
desired  extent.  In  cases  calling  for  amputation  above  the  os  internum, 
it  will  be  better  to  excise  and  remove  the  cervix  first;  then,  by  dilat- 
ing the  upper  canal  sufficiently  to  admit  the  diverging  volsella,  once 
more  proceed  as  in  the  first  instance,  taking  care,  however,  to  keep 
within  bounds.  It  will  be  found  that  the  cupped  stump  can  now  be 
drawn  down  and  made  to  project  as  a  more  or  less  convex  body.  In 
all  cases  the  dome-shaped  electrode  should  be  passed  over  the  entire 
cavity  repeatedly  so  as  to  render  the  cauterization  still  more  complete. 
It  is  important  to  add  that,  in  carrying  the  knife  toward  the  sides  of 
the  cervix,  circular  and  other  arterial  branches  are  likely  to  be  encoun- 
tered, and  hence,  in  this  locality  particularly,  a  high  degree  of  heat  in 
the  platinum  blade  is  to  be  carefully  avoided.  As  an  additional  secu- 
rity against  hemorrhage,  the  convexity  of  the  knife  should  be  pressed 
against  the  external  surface  of  each  particular  section  cut,  so  as  to 
close  the  vessels  more  effectually.  It  is  well  to  state  that  the  metallic 
parts  of  the  electrode  for  the  distance  of  about  two  inches  should  be 
covered  with  a  strip  of  thin  flannel,  so  that  the  vagina  may  be  protected 
from  injury  through  the  reflected  heat."  (See  Results  of  023erative 
Treatment  of  Carcinoma  Uteri.) 

Byrne  claims  for  this  operation  that,  by  the  action  of  heat  on  the 
surrounding  structures,  any  possible  remaining  infection  within  them 
is  destroyed,  and  that  following  the  operation  there  is  an  absence  of 
fever,  and  of  almost  all  pain,  either  pelvic  or  peritoneal;  that  there  is 
almost  universal  immunity  of  the  scar  tissue,  after  cauterization,  from 
secondary  attack  in  the  event  of  the  recurrence  of  the  disease;  and, 
finally,  that  in  the  event  of  i'('laj)Sf',  the  i'(!spite  from  reappearance  of 


458  ^  TEXT-BOOK  OF   GYNECOLOGY 

disease  in  remote  parts,  even  in  the  more  unpromising  cases  of  un- 
doubted circumuterine  infiltration,  is  longer  than  in  other  operations. 

The  results  of  hysterectomy  for  carcinoma  should  be  considered  as 
{a)  immediate,  {h)  remote.  The  immediate  results  are  concerned  with 
the  surgical  recovery  of  the  patient  from  the  operation.  The  remote 
results  take  into  consideration  the  permanency  of  the  cure  thereby 
secured.  One  of  the  most  interesting  of  recent  statistical  researches 
relative  to  the  immediate  results  of  vaginal  hysterectomy  has  been 
conducted  by  Eicard,  of  Paris  {La  semaine  gynecologique,  October  31, 
1899),  who  places  the  primary  mortality  of  vaginal  hysterectomy  at 
the  liands  of  French  surgeons  at  from  16  to  19.68  per  cent.  Monclaire 
and  Picque  place  the  mortality  in  France  at  8.9  per  cent,  this  computa- 
tion being  based  upon  2,376  cases.  Bigeard  concludes,  after  a  careful 
study  of  both  the  French  and  foreign  statistics,  that  the  primary  mor- 
tality from  this  operation  vacillates  between  17  and  20  per  cent.  This 
is  probably  the  representative  figure.  Hofmeier  in  74  vaginal  hyster- 
ectomies reported  a  mortality  of  16.2  per  cent.  Munchmeier  {Frauen- 
arzt)  reported  80  vaginal  hysterectomies  with  4  deaths.  Byrne  finds 
that  in  1,273  colpohysterectomies  by  38  European  and  American  sur- 
geons the  average  primary  mortality  is  14.6. 

The  figures  relating  to  the  remote  or  uUimate  results  of  vaginal 
hysterectomy  for  cancer,  are  less  satisfactory  than  those  relating  to 
primary  results,  for  the  sole  reason  that  it  is  exceedingly  difficult  to 
keep  track  of  the  cases  after  they  once  pass  from  the  surgeon's  hands. 
The  reports  on  this  point  from  various  operators  are  strangely  conflict- 
ing. Thus,  Bouilly  states  that  all  his  cases  operated  ujoon  since  1886 
are  dead;  and  Jacobs  reports  the  same  of  his  annual  series  of  cases 
running  back  respectively  three,  four,  five,  and  six  years.  On  the  other 
hand,  Thorn,  reviewing  the  statistics  of  the  Magdeburg  Clinic,  con- 
cludes that  half  the  cases  in  which  the  disease  is  limited  to  the  uterus, 
operated  upon  in  that  institution,  have  a  permanent  recovery.  Kiche- 
lot  has  cases  alive  six,  eight,  nine,  and  twelve  years,  after  operation. 
Freund  reported  nonrecurrence  in  a  case  eleven  years  after  operation 
and  Olshausen  reported  a  case  of  immunity  after  twelve  years.  Reed 
has  cases  of  nonrecurrence  covering  periods  of  respectively  twelve,  ten, 
nine,  eight,  seven,  six,  five  years  and  less.  McMurtry  has  a  case  of 
nonrecurrence  after  twelve  years,  and  other  American  operators  have 
cases  of  immunity  after  even  longer  periods. 

The  extended  operation  for  carcinoma  of  the  uterus  has  been  followed 
by  results  which  seem  to  justify  its  employment,  particularly  when  it 
is  remembered  that  without  it  the  condition  of  these  patients  is  abso- 
lutely hopeless.    Reis  has  collected  the  tables  of  cases  on  page  459. 

The  primary  results  are  not  so  satisfactory  as  in  vaginal  hysterec- 
tomy, but  they  may  certainly  be  looked  upon  as  justifiable  when  the 
otherwise  hopeless  character  of  the  cases  is  taken  into  consideration. 
The  adoption  of  this  operation  has  been  so  recent  that  ultimate  results 
are  not  yet  determinable. 


NEOPLASMS   OP   THE    UTERUS 


459 


Cases. 

1 
8 

2 

1 
3 

Recoveries. 

Deaths. 

Runipf,  Berlin  {Centralblatt  fur  Oynahologie,  Aug.,  1895) 
Clark,  Baltimore  {Bulletin  of  the  Johns  Hopkins  Hos- 
pital, 1896) ." 

1 
7 
2 
2 

1 

Kiistner,  Bi'eslau  {Feiser  Zeitschrift  fur  Geburtshulfe, 
1898) ' 

Private  coininunicatioii  from  Boston 

1 

Emil  Reis 

1 

Total 

15 

12 

=  80^ 

3 

=  20^ 

The  results  of  electro-hysterectomy  as  practised  by  Byrne,  can  not  be 
designated  by  any  other  term  than  brilliant.  These  results  are  sum- 
marized by  Byrne  himself  in  a  paper  before  the  American  Gyneco- 
logical Society,  1896,  which  begins  with  an  allusion  to  a  previous 
report  to  that  body,  and  is  as  follows: 

"  I  stated  that  in  40  out  of  63  cases  of  cancer  of  the  portio  vaginalis 
(23  having  strayed  away)  periods  of  exemption  from  relapse  were 
obtained  ranging  from  two  to  twenty-two  years,  being  an  average 
of  over  nine  years  for  each;  and  of  50  out  of  81  cases  involving  the 
entire  cervix  (31  being  lost  sight  of),  10  had  an  exemption  from 
recurrence  for  over  two  years,  11  over  three  years,  6  over  four 
years,  8  over  five  years,  6  over  seven  years,  2  over  eleven  years,  1  over 
thirteen  years,  and  1  over  seventeen  years.  Nor  is  this  all,  for  the 
table  would  now  bear  important  reconstruction — no  less  than  6  of  these 
cases,  and  probably  many  more,  having  until  now  enjoyed  a  complete 
immunity.  Moreover,  one  patient  operated  on  in  1875,  and  a  most  un- 
promising case  too,  and  who  could  hot  be  found  at  the  time  of  my 
report,  has  since  been  discovered  by  Dr.  Homer  L.  Bartlet,  of  Flatbush, 
with  whom  I  saw  her,  and  who  was  present  at  the  ojjeration.  Two 
months  ago,  or  nearly  twenty-one  years  after  the  operation,  she  was  in 
perfect  health." 


CHAPTER    XXX 

CiESAREAN   SECTION   AND   ITS   MODIFICATIONS 

Definition  and  historical  resume — Indications — Preparations — Instruments — Posi- 
tion of  cliild  and  placenta — The  operation — After-treatment — Sanger's  method 
— Porro's  modification. 

CiESAEEAN  section  is  an  operation  whereby  an  opening  is  made 
in  the  abdominal  wall^  and  another  in  the  uterus,  through  which*  the 
foetus  is  extracted. 

According  to  Pliny,  it  is  named  Cesarean  because  the  first  of  the 
Cgesars  was  so  extracted  from  his  mother's  womb  as  she  was  dying. 
According  to  another  version  it  is  named  from  the  operation  itself, 
"  cseso  matris  utero." 

This  operation  was  at  first  done  upon  dead  women  at  a  more 
or  less  advanced  stage  of  pregnancy.  It  is  attributed  to  Xuma  Pom- 
pilius,  one  of  the  first  Kings  of  Rome,  who  enacted  {lex  regia)  that  a 
pregnant  woman,  deceased,  must  not  be  interred  until  the  foetus  was 
extracted.  This  law  remained  in  operation  throughout  all  countries 
under  Roman  rule,  and  was  approved  by  the  Church,  as  well  as  adopted 
as  a  civil  law  by  the  ISTorthern  states  of  Europe,  more  especially  Ger- 
many. For  many  years  they  dared  not  perform  the  operation  upon  a 
living  woman,  and  in  this  way  encouraged  the  performance  of  crani- 
otomy, as  the  passage  of  the  foetus  through  the  pelvis  in  cases  of  de- 
formity was  impossible  without  mutilation. 

Levret  and  Mauriceau  deny  that  this  operation  was  known  to  the 
ancients,  but  Dionis  and  Gardien  refer  to  Pliny's  Natural  History. 
Mansfield  published  a  work  On  the  Antiquity  of  Gastrotomy  and  Hys- 
terotomy on  the  Living.  (Ueber  das  Alter  des  Bauch  und  Gebarmut- 
terschnitts  an  Lebenden.  Braunschweig,  1824.)  He  states  that  even 
in  an  earlier  work  than  Pliny's,  named  Mischnajoth,  written  about 
140  B.C.,  there  is  this  passage:  "In  a  twin  birth,  neither  the  first 
child  which  by  section  of  the  belly  is  brought  into  the  world,  nor 
the  one  coming  after,  can  attain  the  rights  of  heirship  or  priestly 
office." 

Xicolai  Falconiis  recorded  a  case  at  Venice  in  1491.  The  case  of 
Jacob  Meter,  the  Swiss  peasant  who  performed  it  upon  his  own  wife, 
is  frequently  quoted,  but  most  authorities  are  agreed  that  it  was  much 
later  before  it  was  generally  attempted  upon  the  living  woman.  In 
fact,  we  need  only  refer  to  the  action  of  Mauriceau  in  the  case  treated 
460 


CiESAREAN  SECTION  AND   ITS  MODIFICATIONS  461 

by  himself  and  Chamberlin,  where  the  operation  was  delayed  until 
after  death,  although  Mauriceau  was  in  actual  attendance  for  several 
days.  He  wrote :  "  The  child  had  been  dead  to  all  appearance  about 
four  days,  and  I  told  all  the  assistants  that  she  could  not  be  delivered. 
They  asked  me  to  perform  Cesarean  section,  which  I  did  not  wish  to 
do,  knowing  that  it  was  always  certain  death  to  the  mother."  This 
poor  woman  died  with  her  infant  in  utero,  twenty-four  hours  after- 
ward. 

Eousset,  physician  to  Catherine  de'  Medici,  and  contemporary  of 
Pare,  published  a  work  upon  the  subject  in  1581.  This  book  was 
translated  into  Latin  about  ten  years  later.  The  author  attempted 
to  prove  the  possibility  of  saving  the  mother  and  child  by  means  of 
this  operation,  but  his  views  were  opposed  by  Pare,  Guillemeau  and 
others.  In  the  middle  of  last  century,  the  subject  divided  operators 
into  two  sections,  the  SympJiysiens  and  Ccesariens,  or  those  who  advo- 
cated division  of  the  symphysis  pubis  and  those  who  advocated  Cesar- 
ean section. 

It  may  be  taken  as  a  recognised  rule  in  midwifery  that  no  woman 
should  be  allowed  to  die  undelivered  without  some  attempt  being  made 
to  save  her  and  her  offspring,  or,  at  least  to  save  her,  even  at  the 
expense  of  her  child. 

Concerning  the  latter  point,  whether  we  are  justified  in  destroying 
the  infant  when  alive,  there  has  been,  and  still  exists,  difference  of 
opinion,  due  in  some  measure  to  religious  belief,  and  likewise  to  the 
personal  feeling  of  the  husband,  who  often  felt  that  very  little  hope 
was  held  out  to  him  that  his  wife  could  be  saved  by  section.  Among 
such  men  we  had  Napoleon,  who,  when  appealed  to  by  Dubois,  said: 
"  Treat  the  Empress  as  you  would  a  shopkeeper's  wife  in  the  Eue  St. 
Martin,  but,  if  one  life  must  be  lost,  by  all  means  save  the  mother."  In 
marked  contrast  to  him  we  had  Henry  VIII,  who,  when  thus  ques- 
tioned before  the  birth  of  his  son  Edward,  exclaimed:  "  Save  the  child 
by  all  means,  for  other  wives  can  be  easily  found."  At  the  present 
time  such  men  might  be  put  down  as  either  a  good  husband  but  a 
bad  father,  or  a  good  father  but  a  bad  husband. 

The  doctrine  of  the  Eoman  Catholic  Church  has  been  that,  even 
though  it  would  be  impossible  to  extract  the  child  without  first  killing 
it,  to  do  so  would  be  mortal  sin;  and  likewise,  until  lately,  it  was  held 
that  the  infant  could  not  be  baptized  in  the  uterus,  as  it  must  be 
natus  before  it  could  be  renatus  by  baptism. 

Of  late  years,  the  happy  results  following  Csesarean  section  and 
Porro's  operation  have  done  much  to  efface  the  dreadful  feeling,  that 
we  have  in  such  cases  to  decide  whether  the  life  of  the  mother  or 
that  of  the  child  is  to  have  our  preference,  seeing  that  it  is  now  quite 
7)Ossib]o  to  save  both. 

7)Mrnos  wrote:  "  Cajsarean  section  is  resorted  to  with  a  feeling 
Mkin  1()  despair.  Embryotomy  stands  first,  and  must  be  adopted  in 
every  case  where  it  can  be  carried  out  without  injuring  the  mother. 


462  ^   TEXT-BOOK  OF   GYNECOLOGY 

Ca3sarean  section  comes  last,  and  must  be  resorted  to  in  those  cases 
Avhere  embrj^otomy  is  either  impracticable,  or  can  not  be  carried  out 
without  injuring  the  mother.  There  is  therefore  no  election.  The 
law  is  defined  and  clear.  Csesarean  section  is  the  last  refuge  of  stern 
necessity." 

As  against  tliis  statement,  Barnes  has  recently  said:  "  It  is  no 
longer  permitted  to  us,  without  ample  j^i'oof  of  clear  necessity,  to 
sacrifice  the  child  in  order  to  save  the  mother.  The  cases  in  which  the 
two  lives  are  supposed  to  stand  in  antagonism  are  vanishing  before  the 
light  of  modern  science  and  skill." 

If  anything  is  needed  to  sicken  one  at  the  revolting  practice  of 
craniotomy,  it  might  surely  be  found  in  the  relation  of  the  obstetrical 
history  of  a  rhachitic  woman,  who  during  her  last  three  confinements 
was  under  the  care  of  ]\Iurdoch  Cameron: 

1st 1862 Euibiyotomy. 

2d 1863 Embryotomy  (laboiu-  induced). 

3d 1864 Einbiyotoiiiy. 

4th 1865 Induced  labour  at  half  term. 

5th Embryotomy  (Birmingham  Lying-in  Hospital). 

6th 1868 Induced  labour  at  half  tei-m. 

7th 1870 Embryotomy. 

8th 1871 Embryotomy  (eiglitli  month). 

9th 1873 Embryotomy. 

10th 1874 Embryotomy. 

11th   1875 Induced  labour  at  half  term. 

AVe  must  never  forget  that  we  have  a  sacred  trust,  and  Cameron 
liolds  that  we  have  no  right  to  sacrifice  a  child,  however  unequal  its 
life  may  be  in  some  cases  to  that  of  the  mother.  In  advocating  the 
preference  for  section  as  against  craniotomy  in  the  living  child,  Came- 
ron does  so  only  after  very  mature  consideration,  and  with  a  feeling 
that  to  do  otherwise  Avotdd  be  to  sacrifice  a  life  which  Ave  are  bound 
to  preserve.  He  thinks  the  time  has  come  Avhen  the  lives  of  the 
mother  and  child  may  alike  be  saved,  and  jDrefers  to  think  that  an 
infant  come  to  maturity  is  destined  for  something  greater  than  to  have 
its  glimmering  life  extinguished  by  an  accoucheur  skilled  in  the  use  of 
a  dreadful  perforator.  Let  our  motto  be,  "  We  live  to  save  and  not 
to  destroy." 

In  another  case  A\'here  the  obstetrical  history  Avas  like  the  preceding 
one,  Csesarean  section  was  performed,  and  the  mother  has  noAv  attained 
her  long-Avished-for  desire,  a  living  child. 

Burns  in  24  cases  gave  22  deaths,  while  others  gave  the  death 
rate  as  from  50  to  100  per  cent. 

With  such  results  it  is  not  to  be  wondered  at  that  so  many  oj^posed 
the  operation.  In  England,  for  example,  accoucheurs  condemned  it 
absolutely.  In  Paris,  during  half  a  century,  there  Avas  not  a  success- 
ful case,  although  it  had  been  performed  about  60  times.  In  the  large 
maternity  hospitals  of  Paris  and  Vienna,  Avith  from  4,000  to  8,000 


C^.SARBAN   SECTION   AND   ITS   MODIFICATIONS 


463 


confinements  in  tlie  year,  not  a  single  successful  case  of  Cassarean 
section  has  been  recorded.  No  doubt  now  exists  that  the  great  fatality 
was  due  to  the  fact  that  the  operation  was  only  resorted  to  after  other 
measures  had  failed. 

Indications  for  the  Operation. — As  regards  the  general  indications 
for  the  operation,  of  course  they  vary  in  the  hands  of  different  opera- 
tors, since  some,  still  looking  upon  Csesarean  section  as  a  last  resource,, 
divide  the  indications  into  absolute  and  relative.  The  absolute  indica- 
tion exists  where  the  deformity  of  the  pelvis  is  so  pronounced  that 
the  passage  of  even  a  mutilated  foetus  is  impossible;  while  the  relative, 
is  where  a  mutilated  foetus  may  be  removed  by  the  natural  passage 
with  as  good  a  result  for  the  mother  as,  or  even  better  than,  that 
afforded  by  embryotomy.  It  is  here  that  difference  of  opinion  exists. 
Baudelocque  admitted  Cesarean  section  in  cases  with  a  conjugate 
diameter  under  24  inches;  Cazeaux,  under  2  inches;  Farnier,  2  inches, 
and  Depaul,  from  1-^  to  2\  inches  when  the  child  was  alive,  and  under 
1-|  inch  when  the  foetus  was  dead.  Stolz  advocated  Csesarean  section 
W"henever  the  child  was  alive,  and  could  not  be  brought  through  the 
natural  passage.     Other  authorities  lay  down  the  limits  as  follows: 


Scanzoni,  under 3  inches. 

Naegele,  under 2      " 

Spiegelberg,  under  2      " 


Barnes,  under H-  inch. 

Playfair,  under 1^     " 

Leishman,  undei' 1^     " 


Of  late  years,  the  good  results  following  Caasarean  section  in  the  hands 
of  Cameron,  Leopold,  Sanger  and  other  operators,  have  materially 
changed  the  views  of  many  authors,  who  now  favour  Csesarean  section 
more  than  they  have  done  in  the  past. 

Lusk,  at  the  International  Congress  held  at  Washington  in  1887,  de- 
clared that  Caasarean  cection  was  preferable  to  embryotomy,  even  with 
a  conjugate  diameter  from  2^  to  3  inches,  when  the  child  was  alive. 

It  can  well  be  urged  that — • 

(1)  Embryotomy  in  a  very  contracted  pelvis  is  as  dangerous  to 
the  mother  as  C^.sarean  section. 

(2)  Embryotomy  always  sacrifices  the  life  of  the  child,  while 
Caesarean  section  gives  a  living  child. 

(3)  No  person  has  any  right  to  sacrifice  a  child  where  they  can 
save  it  without  exposing  the  mother  to  any  additional  risk.  For  these 
reasons  the  operation  should  be  one  of  election  when  the  child  is 
alive,  and  it  should  be  performed  before  the  patient  is  exhausted;  in 
fact,  early  after  ]a1)oiir  has  commenced,  or  even  at  full  term  before 
labour  sets  in,  especially  in  multiparse.  In  all  cases  it  should  be  done 
before  rupture  of  the  membranes,  and  if  possible  the  patient  should 
be  placed  under  the  care  of  an  experienced  operator. 

Little  difficulty  is  experienced  in  obtaining  the  consent  of  the 
patient  and  her  friends,  and  it  is  better  to  have  her  under  observation 
previous  to  the  operation,  so  as  lo  regulate  her  diet,  and  have  her  pre- 
parffl  for  opcral  ion  bcfoi-cliand. 


464  ■        A  TEXT-BOOK  OF   GYNECOLOGY 

A  very  important  23oint  in  favour  of  Ca3sarean  section  is  that  the 
Fallopian  tubes  can  be  tied  and  divided,  so  as  to  prevent  subsequent 
conception,  whereas  embryotomy  may  require  to  be  performed  ten  or 
a  dozen  times. 

Besides  deformity  of  the  pelvis,  other  conditions,  such  as  tumours 
or  cancer  of  the  cervix  uteri,  may  exist,  which  would  demand  either 
Cesarean  section  or  some  modification  of  it. 

If  the  child  is  dead  and  the  conjugate  diameter  not  under  1^  inch, 
Csesarean  section  should  be  done. 

Eousset,  the  earliest  writer  upon  this  subject,  recognised  two  classes 
of  indications,  the  one  furnished  by  the  foetus,  and  the  other  by  the 
mother.  Under  the  first  category  he  placed  excessive  size  of  the  foetus, 
monstrosities,  and  faulty  positions.  Under  the  second,  he  placed 
marked  contractions  from  whatever  cause.  Some  operators  would 
include  placenta  prsevia  and  j)uerj)eral  convulsions.  Csesarean  section 
might  be  advisable  in  some  cases  of  eclampsia,  but  a  skilful  obstetri- 
cian would  never  think  of  such  procedure  in  the  case  of  placenta 
previa.  In  fact,  the  operators  who  advocate  this  step  are  surgeons 
who  have  little  or  no  experience  in  obstetrical  practice. 

Our  decision  for  operation  should  be  based  upon  the  degree  of 
contraction  of  the  pelvis,  the  size  of  the  child's  head,  and  its  reduci- 
bility,  unless  the  obstruction  is  due  to  some  other  cause,  such  as  cancer 
or  the  presence  of  a  tumour  in  the  pelvic  cavity. 

Every  practitioner  should  be  able  to  form  a  fair  estimate  of  the 
amount  of  contraction,  as  it  is  easier  to  measure  a  contracted  pelvis 
than  a  normal  one,  and  it  does  not  require  a  highly  skilled  obstetrician 
to  say  before  labour  has  commenced,  or  during  the  early  stage  of  the 
process,  that  the  diameter  of  the  pelvis  is,  or  is  not,  less  than  3 
inches;  and,  as  a  matter  of  fact,  such  a  pronouncement  should  be 
within  the  skill  of  the  ordinary  practitioner,  who  should  be  more  than 
a  generally  useful  person,  otherwise  he  will  sink  to  the  level  of  an 
ignorant  midwife.  ISTot  only  must  he  be  able  to  form  an  estimate  of 
the  amount  of  contraction,  but  by  patient  study  of  normal  cases,  he 
should  qualify  himself  to  form  an  opinion  as  to  whether  it  will  be 
impossible  for  a  living  child  to  pass,  and  also  whether  under  the  diffi- 
cult circumstances  in  which  he  may  be  placed,  it  would  not  be  better 
to  send  the  patient  where  Cesarean  section  could  be  safely  performed, 
than  to  extract  a  mutilated  foetus  through  a  minimum  diameter. 

With  a  diameter  under  24  inches,  where  engagement  of  the  head 
is  impossible,  no  one  should  hesitate  to  advise  Csesarean  section, 
although  there  will  always  remain  cases,  as  where  the  child  is  dead 
or  a  subject  of  hydrocephalus,  in  which  craniotomy  may  be  resorted  to. 

Experience  alone  will  enable  one  to  avoid  extreme  measures  in 
cases  where  the  conjugate  diameter  measures  more  than  3  inches; 
in  such  cases,  the  skilled  practitioner  will  weigh  the  chances  between 
premature  induction  of  labour  and  symphysiotomy. 

There  can  be  no  question  that  Csesarean  section  is  a  highly  dan- 


CiESAREAN  SECTION  AND   ITS   MODIFICATIONS  465 

gerous  operation,  but  the  danger,  it  should  be  remembered,  de- 
pends for  the  most  part  on  delay,  and  death  most  frequently  results, 
not  so  much  from  the  operation,  as  from  previous  operative  abuse, 
which  is  the  just  term  for  all  injudicious  attempts  to  extract  the  fcetus 
through  a  deformed  natural  passage. 

Success  depends  upon  prompt  interference  before  the  patient  is  ex- 
liausted,  as  then  there  is  less  danger  from  hemorrhage,  delayed  shock 
or  peritonitis. 

When  abdominal  section  has  been  resolved  upon,  another  question 
presents  itself,  namely,  whether  Csesarean  section  or  Porro's  operation 
is  preferable.  If  the  former,  there  still  remains  to  be  decided  whether 
the  operation  shall  be  accompanied  or  followed  by  a  removal  of  the 
■ovaries,  or  the  patient  be  sterilized  by  the  simple  expedient  of  tying 
and  dividing  the  Fallopian  tubes.  This  has  been  done  by  Cameron  in 
about  fifty  cases  and  no  harm  has  resulted,  although  theorists  would 
have  it  believed  that  such  a  procedure  would  be  surely  followed  by 
liematocele.  When  there  is  a  choice  of  operation,  Csesarean  section 
is  to  be  preferred,  as  it  can  be  completed  much  sooner,  and  is  free  from 
the  danger  of  shock  and  peritonitis  which  may  complicate  Porro's 
•operation. 

The  preparation  of  the  patient  will  depend  upon  the  urgency  of 
the  case.  When  she  is  under  observation,  it  is  better  to  confine  her 
to  bed  for  a  couple  of  days  beforehand,  and  the  bowels  should  be 
moved  by  an  enema  and  a  slight  laxative.  The  abdomen  is  washed  and 
gently  scrubbed,  and  the  parts  shaved  while  the  vagina  is  cleansed  and 
rendered  aseptic.  The  preparation  in  fact  is  the  same  as  for  any  other 
•abdominal  section.  The  operator  and  his  assistants  who  have  to  do 
with  the  case  must  be  exceptionally  careful  in  cleansing  and  disinfect- 
ing their  hands,  while  the  chief  nurse  should  see  that  the  instruments 
and  sponges  are  sterilized  and  counted. 

Very  few  instruments  are  necessary.  The  list  should  comprise 
the  following: 


•Scalpels 2 

Blunt-pointed  bistoury 1 

Forceps,  pressiu'e 8 

Dissecting ...  2 

Scissors. 

Director 1 


Needles,  Hagedorn's  2i-inch  straight.   20 

Pessary,  compression 1 

Silk,  antiseptic. 
Silkworm  gut. 
Adhesive  plaster. 
Dressings. 


The  catheter  should  always  be  passed  into  the  bladder  shortly  be- 
fore operation.  The  needles  should  be  threaded  in  pairs  beforehand, 
with  No.  3  Chinese  twist  silk  ligatures,  about  30  inches  long,  and  placed 
in  a  towel  wrung  out  of  l-to-30  carbolic  solution,  ready  for  use. 

Palpation  will  reveal  the  position  of  the  fcetus,  and  this  is  all  the 
more  important,  as  from  this  the  attachment  or  site  of  the  placenta 
Avill  be  known. 

Cameron's  experience  in  Csesarean  section  has  shown  him  that  in 
"dorso-postorior  positions  the  placenta  is  attached  upon  the  anterior 


466 


A  TEXT-BOOK  OF  GYNECOLOGY 


wall,  while  in  dorso-anterior  positions  the  placenta  is  upon  the  pos- 
terior wall.     Thus: 

(a)  In  the  first  cranial  position,  or  O.L.A.,  the  placenta  will  be 
found  upon  the  posterior  wall,  and  somewhat  to  the  right  side. 

(b)  In  the  second  cranial  position,  or  O.D.A.,  the  placenta  will  be- 
upon  the  posterior  wall,  and  somewhat  to  the  left  side. 

(c)  In  the  third  cranial  position,  or  O.D.P.,  the  placenta  will  be 
upon  the  anterior  wall,  and  somewhat  to  the  left  side. 

(d)  In  the  fourth  cranial  position,  or  O.L.P.,  the  placenta  will  be 
upon  the  anterior  wall,  and  somewhat  to  the  right  side. 

The  fcetus  and  placenta  will  be  found  in  the  same  relation  in  the 

various  pelvic  positions. 

From  this  information  it  is  eas}^  to  know  when  the  uterine  incision 

is  likely  to  cut  down  upon  the  placenta,  and  an  idea  can  also  be  formed 

as  to  how  to  extract  the  foetus. 

The   Operation. — The  abdominal  incision   should  be  made  in  the 

median  line  as  in  ovariotomy,  and  it  will  vary  in  situation  according 

to  the   distention  of  the  ab- 
dominal wall. 

Thus,  if  the  abdomen  does, 
not  droop  (Fig.  200),  an  inci- 
sion from  5  to  6  inches  in 
length  may  be  obtained  with- 
out extending  beyond  the  um- 
bilicus; but  when  it  is  pen- 
dulous (Fig.  201),  the  incision 
must  of  necessity  extend 
more  or  less  above  the  um- 
bilicus. 

Before  opening  the  uter- 
us, the  operator  should  satisfy 
himself  that  that  organ  is  not 
only  in  the  median  line,  but 
that  it  is  not  twisted  upon  its- 
axis.  This  is  settled  by  locat- 
ing the  position  of  the  Fallo- 
pian tubes  by  means  of  the 
fingers.  He  will  frequently 
find  the  left  tube  more  or 
less  in  front,  as  the  uterus  is- 
usually  rotated  to  the  right. 

This  displacement  must  be  corrected,  and,  if  necessary,  an  assistant 

can  easily  keep  the  uterus  in  position  by  pressing  with  his  hand  on 

the  right  side. 

When  the  placenta  has  its  attachment  upon  the  anterior  wall  the 

site  is  seen  to  bulge,  and  upon  palpation  has  a  fluctuating  feeling  akiiL 

to  that  of  a  large  pointing  abscess. 


Fig.  200. — "  If  the  abdomen  does  not  droop." — 
Cameron. 


CESAREAN  SECTION   AND  ITS   MODIFICATIONS 


407 


The  next  point  is  to  open  the  uterus  with  as  little  loss  of  blood 
as  possible,  and  this  can  be  done  by  placing  a  flat  Aoilcanite  pessary 
upon  the  uterine  wall  around  the  point  to  be  incised  (Fig.  202). 

The  operator,  with  the  fingers  of  his  left  hand,  applies  pressure 
upon  the  pessary,  while  his  assistant  does  the  same  on  the  opposite 
side.  The  incision  is  then  made  with  two  or  three  strokes  of  the  scal- 
pel, and  the  blood  sponged  away  by  the  assistant  with  his  right  hand. 
After  this  has  been  done,  no  more  bleeding  takes  place  until  the 
placenta  is  attacked  in  front,  as  the  pressure  with  the  pessary  thor- 
oughly prevents  even  oozing.  Care  should  be  taken  not  to  puncture 
the  membranes,  which  will  soon  be  observed  and  recognised  by  their 
pearly  colour.  If  the  placenta  intervenes,  this  method  of  pressure 
is  beneficial,  not  only  in  preventing  bleeding,  but  also  in  permitting 
observation  of  its  tissue,  which  is  recognised  by  its  darker  colour. 

Whenever  the  membranes  are  reached,  a  director  is  placed  within 
the  opening,  which  is  then  enlarged  with  a  blunt-pointed  bistoury 
upward  and  downward  as  far  as  the  pessary  will  admit.  At  this  stage, 
the  compression  pessary  is  removed  and  the  incision  extended  upward 
and  downward  sufficiently  to  permit  the  passage  of  the  foetus.  The 
extension  of  the  incision 
downward  should  be  limited, 
as  it  is  likely  to  interfere  with 
proper  contraction  of  the 
uterus.  Should  the  placenta 
intervene,  it  must  be  dealt 
with  as  a  placenta  previa 
after  completing  the  incision, 
that  is,  either  separated  upon 
one  side,  or  if  central,  pierced 
by  the  hand.  There  must  be 
no  hesitation  in  extending 
the  incision,  which  is  made 
upward  and  downward  from 
within  outward  in  each  direc- 
tion with  a  blunt-pointed  bis- 
toury, to  the  length  of  about 
5  or  6  inches.  The  left  hand 
is  inserted  without  rupturing 
the  membranes  till  the  head 
is  being  turned  out,  or  the 
feet  grasped,  and  then  the 
child  should  be  extracted 
without  delay.  On  no  ac- 
count   should    the    hand    be 

withdrawn  after  its  insertion,  unless  during  extraction  of  the  foetus, 
as  the  uterus  speedily  contracts.  If  the  shoulder  presents,  a  hand 
shouhl  bo  placed   upon  it  to  prevent  its  expulsion,  as  it  adds  very 


Fig.  201.— "When  it  is  pendulous,  the  incision 
must  extend  more  or  less  above  the  umbili- 
cus."— Cameron  (page  466). 


468 


A  TEXT-BOOK  OP   GYNECOLOGY 


much  to  the  difficulty  when  any  portion  of  the  child's  body  is  allowed 
to  protrude. 

The  child  having  been  extracted,  the  assistant  places  a  large  flat 
sponge  over  the  upper  angle  of  the  abdominal  incision,  to  prevent  the 
bowels  from  escaping,  and  then  with  both  hands  grasps  the  uterus, 
so  as  to  prevent  bleeding. 

The  cord  having  been  tied  and  divided,  the  placenta  is  immediately 
removed  with  the  left  hand,  great  care  being  taken  to  secure  the  re- 
moval of  all  membranes  and  to  prevent  the  entrance  of  blood  into 
the  peritoneal  cavity.  The  assistant  now  everts  the  uterus  from  the 
cavity,  and  pushes  a  flat  sponge  behind  it.  The  lips  of  the  uterine 
wound  are  next  everted,  the  assistant  grasping  the  upper  angle  and 
wall  with  his  right  hand,  and  the  lower  angle  and  wall  with  the  left. 
While  the  assistant  holds  the  wound  thus,  the  operator  immediately 
inserts  the  silk  ligatures,  beginning  at  the  middle,  each  suture  grasp- 
ing the  entire  wall  with  the  exception  of  the  mucosa  (Fig.  203).  From 
seven  to  ten  sutures  should  suffice,  as,  with  the  contraction  of  the 
uterus,  the  incision  is  greatly  diminished. 

This  accomplished,  the  sutures  are  gathered  up,  a  large  flat  sponge 
laid  over  the  anterior  wall,  and  another  behind.     Firm  compression  or 

kneading  is  then  made 
T^^'i^WMt,!  through  the  sponges 
with  the  result  that  the 
uterus  contracts  firmly. 
The  assistant  should 
again  seize  the  uterus 
as  before,  while  the  op- 
erator ties  the  sutures. 
When  this  has  been  ac- 
complished, the  whole 
organ  is  enveloped  in  a 
large,  warm,  flat  sponge, 
and  firm  comjaression  is 
again  made  so  as  to  in- 
sure thorough  contrac- 
tion. Should  any  ooz- 
ing appear  at  the  nee- 
dle punctures,  a  second 
warm  sponge  should  be 
applied,  and  very  slight 
compression  will  suffice 
to  overcome  any  tend- 
ency to  relaxation. 
Should  the  peritoneal 
edges  gape  at  any  points,  a  few  superficial  fine  sutures  should  be  in- 
serted to  bring  the  margins  together. 

The  performance  of  hysterectomy  for  bleeding  is  bad  treatment. 


Fig.  202. — "Placing  a  flat  vulcanite  pessary  upon  the 
uterine  wall  around  the  point  to  be  incised." — Cam- 
eron (page  467). 


CESAREAN  SECTION  AND  ITS   MODIFICATIONS 


469 


and  indicates  that  the  operator  has  lost  his  nerve,  as  pressure  with 
a  warm  sponge  with  both  hands  never  fails  to  secure  thorough  con- 
traction. 

Several  operators  advise  the  introduction  of  a  drainage  tube 
through  the  cervix  and  vagina,  and  the  leaving  it  there  to  act  as  a 
drain.  Nothing  could  be  worse.  Of  course,  it  is  the  procedure  of  a 
surgeon,  but  every  one  who  has  practised  midwifery  knows  that  the 
presence  even  of  a  clot  in  the  uterus  may  lead  to  serious  hemorrhage. 
Such  a  body  as  a  tube,  if 
not  expelled,  woiild  in- 
duce hemorrhage,  disten- 
tion of  the  uterus,  and 
bursting  of  the  incision 
with  speedy  death  of  the 
patient.  This  is  no  mere 
theory,  but  is  what  has 
actually  taken  place 
where  drainage  has  been 
resorted  to.  On  no  con- 
dition should  the  uterine 
cavity  be  washed  out  or 
medicated  in  any  way. 
The  less  the  parts  are  in- 
terfered with  the  better. 

After  the  ligatures 
have  been  cut  short,  the 
next  step  is  to  ligature 
the  Fallopian  tubes  with 
antiseptic  silk  and  divide 
them,  in  order  to  prevent 
future  conception.  Of 
course,  the  consent  of  the 
patient  for  this  procedure 
should  be  obtained  be- 
forehand. Two  ligatures 
are  tied  upon  each  tube, 
which  is  then  divided  be- 
tween those  points.    This 

method  is  effective,  and  leads  to  no  complications  or  bad  results,  nor 
is  menstruation  interfered  with.  The  cavity  is  next  cleaned  by  the 
removal  of  all  clots,  etc.,  and  the  uterus  replaced.  The  external  wound 
in  the  parietes  is  closed  in  the  usual  way  with  silkworm  sutures.  The 
vagina  should  now  be  cleansed  of  all  clots  and  sponged  out,  after 
which  an  antiseptic  pad  should  be  applied  to  the  vulva. 

The  wound  should  be  dusted  with  iodoform,  and  a  few  layers  of 
gauze  placed  over  the  wound.  This  should  be  secured  with  plaster, 
to  prevent  botli   slipping  of  the  dressing  and  strain  on  the  sutures, 


Fig.  203. — "The  operator  immediately  inserts  the  silk 
ligatures,  each  suture  grasping  the  entire  wall  with 
the  exception  of  the  mucosa." — Cameron  (page  468). 


470 


A  TEXT-BOOK  OF  GYNECOLOGY 


in  case  of  sickness  or  cough.    A  sheet  of  gamgee  or  other  dry  absorbent 
dressing  is  next  ajDplied,  and  then  the  bandage. 

The  after-treatment  consists  of  sips  of  warm  water,  say  a  teaspoon- 
ful  every  fifteen  minutes  for  twelve  or  twenty-four  hours,  after  which 
milk  and  soda  may  be  given  in  increasing  quantities.  For  a  few 
nights,  half  a  grain  of  morjDhine  in  suppository  is  given.  The  urine 
should  be  drawn  off  every  six  hours  for  two  or  three  days,  care  being 
taken  to  cleanse  the  parts  thoroughly  before  doing  so. 

On  the  fourth  day,  an  enema  of  two  teaspoonfuls  of  glycerine  in 
two  ounces  of  soapy  water  is  administered,  and,  if  necessary,  some 
slight  aperient  by  the  mouth.  The  bowels  having  been  moved,  the 
patient  is  allowed  chicken  soup,  fish,  eggs,  beef  tea,  etc.  If  the  child 
is  to  be  nursed,  it  may  be  put  to  the  breast  on  the  second  or  third  day. 
The  abdominal  sutures  may  be  removed  in  from  ten  to  fourteen 
days,  and  the  patient  allowed  to  rise  at  the  end  of  four  weeks.  She 
sliould  always  wear  an  abdominal  belt,  and  should  be  warned  against 
kneeling  when  scrubbing  floors,  etc.,  as  this  is  apt  to  induce  hernia 
from  pressure  and  stretching  of  the  cicatrix. 

In  review,  it  may  be  explained  that  rupture  of  the  membranes, 
either  intentionally  or  by  labour,  means  a  contraction  of  the  uterine 
wall,  and  as  a  consequence  a  greater  wounding  of  the  uterine  tissue, 
in  order  to  secure  a  sufficient  opening  to  extract  the  child.  Some 
operators,  instead  of  using  manual  or  pessary  compression  to  prevent 
bleeding  when  opening  the  uterus,  employ  an  elastic  ligature.  The 
uterus  is  first  everted,  and  the  elastic  ligature  is  then  passed  round 
the  cervix.  This  not  only  necessitates  a  much  larger  abdominal  inci- 
sion, but  also  induces  asphyxia  of  the  foetus  and  causes  inertia  of  the 
uterus,  as  the  organ  does  not  so  readily  respond  to  kneading.  Its 
employment  is  therefore  conducive  to  hemorrhage.  Veit,  Doleris, 
and  Pajot,  have  blamed  it  for  causing  death  from  hemorrhage,  and 
Zweifel,  Sanger,  and  Lusk,  have  also  noticed  this  complication. 

Carniso  advised  the 
early  removal  of  the 
ligature. 

Sanger's    method    is 
another  way   of   dealing 
with  the  uterine  incision 
(Fig.  204).     In  this  pro- 
cedure,     the      muscular 
wall    of    the    uterus    is 
closed  with  from  ten  to 
fifteen  sutures  which  ap- 
proximate to,  but  do  not 
include,  the  mucosa,  and 
between   each   suture   two    superficial    sutures   are   inserted    to   unite 
peritoneum  to  peritoneum.     Formerly,  the  peritoneum  was  separated 
from  the  muscularis,  and  a  wedge-shaped  piece   of  muscularis   was 


Fig.  204. — "  Sanger's  metliod  is  another  way  of  dealing 
with  the  uterine  incision." — Cameron. 


CESAREAN"  SECTION  AND   ITS   MODIFICATIONS  47 1 

removed  from  each  side,  the  base  of  the  wedge  being  outermost. 
This  done,  the  peritoneal  flaj)s  were  folded  into  the  wound  and  se- 
cured by  the  superficial  stitches.  Such  a  detailed  process  is  quite 
unnecessary,  as,  the  sutures  as  recommended  by  Cameron  secure 
perfect  apposition,  not  only  of  the  muscular  tissue,  but  also  of  the 
peritoneum.  In  fact,  most  operators  now  make  use  of  only  eight 
or  ten  deep  sutures,  and  reserve  superficial  sutures  to  secure  con- 
tact where  there  is  any  gaping  between  the  stitches.  Such  uneven- 
ness  can  be  readily  avoided  by  beginning  in  the  middle  and  working 
toward  each  end,  and  by  taking  care  to  keep  the  sutures  at  regular 
intervals. 

Porro's  Modification. — The  fatal  results  following  the  early  Caesa- 
rean  section  led  to  a  modification  of  the  operation.  It  had  been  found 
by  experiment  that  the  uterus  in  pregnant  rabbits  could  be  removed 
with  better  results  than  by  simple  section,  and  therefore  it  was  con- 
cluded that  similar  results  would  follow  in  the  case  of  women. 

Blundell,  in  writing  upon  this  subject,  said  such  a  method  might 
prove  an  eminent  and  valuable  imj^rovement,  but  he  also  wrote,  in 
speaking  of  deaths  from  peritonitis  after  Cesarean  section,  that  ex- 
perience sometimes  contradicted  our  most  cherished  opinions,  and  that 
something  of  the  kind  would  be  found  to  occur  in  the  cases  under 
consideration,  as  he  had  no  doubt  that  the  risk  of  diffused  peritonitis 
had  been  greatly  exaggerated.  How  his  surmise  has  proved  true,  is 
■seen  in  the  present-day  position  of  abdominal  surgery. 

Acting  on  the  lines  suggested,  Storer,  of  Boston,  in  1868,  first  prac- 
tised amputation  of  the  uterus  after  section.  The  case  was  one  of 
pregnancy  complicated  with  a  fibroid  of  the  uterus.  He  was  inter- 
rupted by  such  an  alarming  hemorrhage  that  he  had  to  remove  the 
body  and  fundus  with  the  ovaries,  but  his  patient  died  three  days  after- 
ward.    This  was  an  operation  of  necessity. 

Porro  first  performed  the  operation  as  a  matter  of  choice,  as  he 
considered  it  impossible  to  secure  the  uterine  incision  in  Ca3sarean  sec- 
tion so  fully  as  to  prevent  the  flow  of  blood  and  septic  fluid  into  the 
peritoneal  cavity.  The  results  obtained  under  antiseptics  in  other 
abdominal  operations  encouraged  him  to  make  the  attempt,  and  in 
1876  he  did  so  with  happy  results.  Others  took  up  the  operation,  and 
very  quickly  the  old  Cscsarean  section  was  superseded  by  it;  but  only 
for  a  few  years,  for  Caesarean  section  can  now  be  performed  without 
the  slightest  danger  from  bleeding,  peritonitis,  septicsemia,  or  other 
dangers,  that  Porro's  operation  sought  to  avert. 

At  the  present  day,  Porro's  operation  is  an  operation  of  exception, 
that  is,  only  necessary  in  some  conditions,  such  as  serious  rupture  of 
the  uterus,  or  where  labour  is  obstructed  by  a  large  fibroid.  As  regards 
the  steps  of  the  operation,  it  is  at  the  beginning  similar  to  Caesarean 
section.  But  after  the  uterus  has  been  emptied  it  varies,  inasmuch 
as  at  this  point  the  uterus  is  everted  and  an  elastic  ligature  applied 
round  it.  Just  above  the  os  internnin.     The  uterine  tissues  are  then 


472  ■        A  TEXT-BOOK  OF   GYNECOLOGY 

compressed  until  the  bleeding  has  ceased.  Then  the  uterus  is  re- 
moved, the  stump  secured  outside  the  abdominal  wound,  and  main- 
tained in  position  by  needles  and  a  serre-noeud. 

Porro,  upon  emptying  the  uterus,  transfixed  it  with  a  trocar  and 
cannula  at  the  union  of  the  body  and  cervix.  He  then  withdrew  the 
trocar  and  passed  two  silver  wires  through  the  cannula,  which  was  alsa 
withdrawn  and  the  wires  tied,  one  upon  the  right  and  the  other  upon 
the  left  side,  including  in  their  grasp  the  ovaries  and  tubes.  This 
done,  the  uterus  and  appendages  above  the  wires  were  cut  away,  while 
the  stump  was  secured  outside.  The  method  has  been  improved  by 
transfixing  with  needles  and  ligating  with  a  serre-nceud  instead  of  with 
separate  wires. 

The  stump  is  dusted  with  iodoform,  and  dressed  with  gauze  all 
round.  The  needles  should  be  raised  to  allow  of  proper  packing.  A 
layer  of  sublimated  gamgee  or  other  dry  absorbent  dressing  should  be 
placed  over  all.  It  may  require  to  be  dressed  daily,  and  the  ligated 
portion  usually  separates  about  the  tenth  day,  but  the  raw  cavity  re- 
quires regular  dressing  until  perfectly  healed. 

It  was  urged  as  an  important  factor  that  Porro's  operation  pre- 
vented future  conceptions,  but  this  end  is  gained  in  Cesarean  section 
by  the  more  simple  method  of  tying  and  dividing  the  tubes. 

Some  operators  now  prefer  to  remove  the  entire  uterus. 


CHAPTER    XXXI 

MALFORMATIONS   AND   DISPLACEMENTS   OF   THE 
FALLOPIAN   TUBES 

Absence  and  defective  development  of  the  tubes  —  Supernumerary  and  accessory 
tubes  and  ostia — Displacements  of  the  Fallopian  tubes. 

The  Fallopian  tubes  develoj)  from  the  upper  ends  of  the  two 
Miillerian  ducts.  Their  anlagen  are  first  solid  and  cordlike  and  later 
become  hollow  tubes,  and  their  lower  limit  is  marked  by  the  milage 
of  the  round  ligament.  Below  this  level  the  Miillerian  ducts  unite 
to  form  the  uterus  and  vagina.  Their  malformations  may  be  marked 
by  the  characters  of  defect,  of  excess,  or  of  altered  relation.  During 
foetal  life  each  Fallopian  tube  shows  several  spiral  convolutions. 

Absence  and  Defective  Development  of  the  Tubes. — ^Absence  of  both 
tubes  is  very  rare,  and  when  it  occurs  it  is  nearly  always  associated  with 
absence  of  the  uterus.  A  less  rare  anomaly  is  absence  of  one  tube, 
and  in  such  a  case  the  corresponding  ovary  is  said  to  be  usually  wanting 
also;  but  this  is  probably  less  often  so  than  has  been  thought,  for  the 
gland  may  be  present  in  a  rudimentary  state,  as  in  the  specimen  de- 
scribed by  Blot  (Comptes  rendus  de  la  Societe  de  hiologie,  2.  s.,  vol.  iii,  p. 
176, 1857),  or  in  an  unusual  position  in  the  abdominal  cavity.  Very  fre- 
quently the  defect  is  associated  with  the  uterine  malformation  known 
as  uterus  unicornis;  it  is  easy  to  understand  this  combination  of  de- 
fects when  it  is  borne  in  mind  that  the  tube  and  the  corresponding 
half  of  the  uterus  are  both  developed  from  the  same  duct  of  Miiller. 
Unilateral  absence  of  the  tube  is  not  necessarily  accompanied  by  in- 
terference with  the  reproductive  functions,  for  Chavannaz  (Journal  de 
medecine  de  Bordeaux,  vol.  xxvi,  p.  361,  1896)  has  recorded  the  case, of  a 
woman  of  sixty  who  had  menstruated  regularly  and  had  borne  three 
children,  and  who  yet  possessed  (as  was  found  out  at  the  autopsy) 
neither  tube  nor  ovary  on  the  right  side.  The  kidney  of  the  same 
side  may  also  be  wanting,  as  in  Edridge-Green's  case  (British  Medical 
Journal,  1895,  vol.  i,  p.  416).  The  Fallopian  tube  may  be  absent 
in  part,  for  Ballantyne  and  Williams  (Structures  in  the  Mesosalpinx, 
p.  20,  1893)  have  described  a  case  of  genital  tuberculosis  in  which  the 
outer  two  thirds  of  the  right  tube  was  completely  wanting  and  the 
inner  third  ended  in  a  tapering  conelike  extremity  (Fig.  205).  Some- 
times the  tube  shows  its  rudimentary  development  by  its  solid  state 
or  by  iniperforation  of  its  abdominal  end,  anomalies  which  a  knowledge 

473 


474  ^  TEXT-BOOK  OF   GYNECOLOGY 

of  embryology  makes  it  easy  to  comprehend.  Another  form  which 
rudimentary  development  of  the  tube  may  take,  is  persistence  of  the 
spiral  convolutions  which  are  normally  present  in  foetal  life;  it  is 
doubtful  whether  these  twists  represent  a  return  to  the  foetal  state  or 
a  continuance  of  it;  they  must  predispose  to  the  occurrence  of  hydro- 
salpinx, and  they  may  lead  to  sterility  and  dysmenorrhoea. 


Pig.  205. — "  A  case  of  genital  tuberculosis  in  which  the  outer  two  thirds  of  the  right  tube 
•was  completely  wanting  and  the  inner  third  ended  in  a  tapering  conelike  extremity." 
— Ballantyne  (page  473). 

Supernumerary  and  Accessory  Tubes  and  Ostia. — Cases  of  super- 
numerary or  double  tubes  are  exceedingly  rare;  but  instances  of  acces- 
sory ostia  or  of  small  tubes  attaclied  to  the  broad  ligament  or  to  the 
Fallopian  tube  itself  are  comparatively  common.  It  is  not  difficult  to 
understand  why  this  should  be  so,  for  in  the  former  case  it  is  necessary 
to  suppose  the  existence  of  two  Mlillerian  ducts  on  one  side,  while  in 
the  latter  the  condition  may  be  explained  by  anomalous  development 
of  a  single  duct.  An  example  of  true  double  tube  (on  the  right  side) 
was  reported  by  Winckel  (LeJirbuch,  p.  595,  1886);  there  was  a  third 
ovary  lying  in  front  of  the  uterus,  and  attached  to  it  was  a  cordlike 
structure  with  a  fimbriated  end  which  passed  to  the  right  side  and  was 
connected  with  the  right  Falloj^ian  tube;  the  patient  was  sterile.  The 
case  described  by  Euppolt  (Archiv  fiir  Gynakologie,  vol.  xlvii,  p.  646, 
1894)  must  be  looked  upon  as  one  of  constriction  of  a  Fallopian  tube  by 
fcfital  peritonitis,  and  not  as  true  duplication  of  the  tube.  With  regard 
to  Wetherill's  case  of  "  supernumerary  oviducts  "  {American  Jour^ial 
of  Obstetrics,  vol.  xxxiv,  p.  373,  1896),  some  doubt  must  also  exist  as  to 
whether  the  tubes  running  in  the  broad  ligaments  below  and  parallel 
with  the  normal  Fallopian  tubes  were  really  salpingeal  in  nature  or  not. 

Accessory  ostia  and  tubes  are,  as  has  been  said,  not  so  uncommon. 
Ballantyne  and  Williams  {Structures  in  the  Mesosalpinx,  p.  25, 1893)  met 
with  two  instances  of  accessory  ostia  in  sixty-one  pairs  of  tubes  from 


MALFOEMATIONS  OF  THE  FALLOPIAN  TUBES 


475 


Fig.  206. — "  Usually,  one  accessory  ostium  only  is 
present." — Ballantyne. 


consecutive  post-mortems  at  the  Edinburgh  Royal  Infirmary.  Usually, 
one  accessory  ostium  only  is  present  (Fig.  306),  and  it  is  situated  on 
the  upper  margin  of  the  tube  not  far  from  its  normal  ostium;  but  Fer- 
raresi  (Annali  di  ostetricia,  ginecohgia  e  pediatria,  vol.  xvi,  p.  531,  1894) 
has  put  on  record  a  re- 
markable case  in  which 
there  were  six  ostia  in  all. 
They  are  either  sessile  on 
the  normal  tube  or  have 
longer  or  shorter  pedicles 
connecting  them  with  it. 
These  pedicles  may  be  hol- 
low, and  generally  the 
ostia  are  surrounded  by 
fimbrice  and  communicate 
with  the  tubal  lumen. 
They  may  arise  either  from 
imperfect  closure  of  the 
groove  in  the  germinal  epi- 
thelium   which    ultimately 

becomes  the  ujDper  end  of  the  duct  of  Miiller,  or  from  secondary  opening 
of  the  duct  after  it  has  been  closed.  The  structures  which  have  been 
described  must  not  be  confounded  with  what  have  been  called  "  tubal 
appendages "  or  "  pedunculated  tufts  of  fimbrige."     These  are  solid 

stalks  bearing  nu- 
merous fimbrige  on 
their  free  end,  and 
they  usually  spring 
from  the  broad  liga- 
ment in  the  neigh- 
bourhood of  the  par- 
ovarium. Ballantyne 
and  Williams  (loc. 
cit.,  p.  45)  have 
shown  how  frequent- 
ly stalked  cysts  of 
the  tubules  of  Ko- 
belt  occupy  this  po- 
sition (Fig.  207),  and 
it  is  quite  possible, 
as  Bland  Sutton  sug- 
gests, that  the  pe- 
dunculated tufts  of 
fimbriffi  are  simply  ruptured  cysts  of  Kobelt's  tubes.  A  com- 
parison of  Ballantyne  and  Williams's  representation  of  such  a  cyst 
and  Kubc's  case  of  accessory  tubal  appendages  (Fig.  208)  will 
strengthen   tliis   view.     It  is  noteworthy,   however,  that  in   the   dis- 


FiG.  207.— "  Frequently  stalked  cysts  of  the  tubules  of  Kobelt 
occupy  this  position." — Ballantyne. 


476  "       A  TEXT-BOOK  OF  GYNECOLOGY 

cussion  which  followed  the  reading  of  Kube's  j^aper  (Journal  ATcou- 
scherstva  I  Gienshich  Boliesneij,  vol.  ix,  p.  458,  1895),  Massen  stated  that 
so-called  parovarian  cysts  might  arise  from  these  accessory  tufts  of 
fimbrige.    The  question  must,  therefore,  be  left  undecided  in  the  mean- 


FiG.  208. — "  Kube's  case  of  accessory  tubal  appendages." — Ballantyne  (page  475). 

time.  Tubal  diverticula  are  sometimes  met  with,  and  it  has  been  haz- 
arded that  their  rujDture,  followed  by  the  prolapse  of  the  tubal  folds 
through  the  opening  thus  formed,  may  lead  to  the  production  of  an 
accessory  ostium. 

From  the  clinical  standpoint,  accessory  tubal  ostia  and  diverticula 
are  not  unimportant;  indeed,  the  opinion  has  of  late  years  been  grow- 
ing that  they  stand  in  very  close  relation  with  the  causation  of  extra- 
uterine gestation.  Thus  Henrotin  and  Herzog  {Revue  de  gynecologie 
et  de  chirurgie  ahdominale,  vol.  ii,  p.  633,  1898)  have  reported  two  cases 
in  which  they  regarded  tubal  malformations  as  the  cause  of  ectopic 
pregnancy:  in  one,  the  abdomen  was  opened  for  symptoms  of  tubal  rup- 
ture, and  it  was  found  that  below  the  right  tube  was  a  small  accessory 
tube  with  a  complete  ostium  abdominale,  and  in  it  a  sac  containing 
blood  clot,  decidual  cells,  and  chorionic  villi;  in  the  other,  the  uterus 
and  appendages  were  removed  for  long-continued  pelvic  symptoms,  and 
it  was  seen  that  from  the  left  Fallopian  tube  near  its  middle  a  diver- 
ticulum projected  toward  the  uterus,  and  in  this  there  were  also  blood 
clot,  decidual  cells,  and  chorionic  villi.  On  the  other  hand,  an  acces- 
sory ostium  tubee  may  render  possible  the  occurrence  of  jDregnancy 
when  the  normal  tubal  ostia  on  both  sides  of  the  body  are  closed  by 
inflammatory  adhesions,  as  in  the  remarkable  case  described  by  Sanger 


DISPLACEMENTS   OP   TPIE   FALLOPIAN   TUBES  4YY 

{Monatsschrift  fiir  Geburtshulfe  und  Gyndkologie,  1895,  vol.  i;,  p.  21, 
Bovee  {National  Medical  Review,  July,  1899)  reported  a  case  in  which, 
in  an  operation  for  adhesion  of  the  appendages  and  retroversion  of  the 
uterus,  examination  of  the  right  appendage  showed  two  fimbriated  tube 
ends.  Through  the  upper  tube  a  probe  could  be  passed  almost  to  the 
uterine  cornu;  the  other  was  permeable  to  the  probe  for  about  2  inches, 
but  as  the  passage  of  a  probe  all  the  Avay  to  the  uterine  from  the  am- 
pullar end  of  a  tube  is  rarely  possible,  it  seemed  probable  that  there 
were  really  two  similar,  normal  tubes  in  this  case. 

Displacements  of  the  Fallopian  Tubes. — The  tube,  like  the  ovary, 
may  be  congenitally  displaced.  It  may,  for  instance,  be  at  a  higher 
level  than  normal  in  the  abdominal  cavity.  In  the  case  of  a  newborn 
infant,  J.  W.  Ballantyne  {Transactions  of  the  Edinburgh  Obstetrical 
Society,  vol.  xv,  p.  56,  1890)  found  the  right  Falloj)ian  tube  adherent, 
through  foetal  peritonitis,  to  the  peritoneal  aspect  of  the  caecum;  and 
M.  L.  Harris  {American  Gynecological  and  Obstetrical  Journal,  vol.  viii, 
p.  45,  1896)  discovered,  during  abdominal  section  performed  for  men- 
strual pain,  that  the  right  tube  was  much  longer  than  usual  and  passed 
to  the  right  ovary  which  lay  on  the  psoas  magnus  as  high  as  the  bifur- 
cation of  the  aorta.  A  case  is  on  record  (Hiiter,  Monatsschrift  fiir 
Gehurtshidfe,  vol.  xxv,  p.  424,  1865)  in  which  the  tubes  were  displaced 
hackward,  and  were  united  behind  the  uterus  by  their  ostia,  forming  a 
ring.  Another  type  of  tubal  displacement  is  herniation.  Just  as 
hernia  of  the  ovary  into  the  inguinal  canal  may  occur,  so  the  tube  may 
find  its  way  in  the  same  direction.  Usually,  the  tube  is  herniated  along 
with  the  ovary  (see  Malformations  of  the  Ovary),  but  in  exceptional 
cases  it  has  been  met  with  alone.  Thus,  Pierre  Wiart  {Bulletins  et 
memoires  cle  la  Societe  anatomique  de  Paris,  6.  s.,  vol.  i,  p.  59,  1899) 
has  reported  the  case  of  a  six-months'-old  child  with  hydrocephalus,  in 
which  the  uterus  was  displaced  toward  the  left  side,  the  tube  and  round 
ligament  of  the  same  side  were  engaged  in  the  abdominal  opening  of 
the  inguinal  canal,  and  the  tube  inside  the  canal  was  disjDosed  in  the 
shape  of  an  almost  complete  0,  the  fimbriated  end  coming  nearly  into 
contact  with  the  part  immediately  projecting  from  the  orifice.  The 
ovary  lay  near  to  the  opening  but  did  not  engage  in  it.  It  is  probable 
that  this  form  of  hernia  is  more  common  than  has  been  thought;  it  may 
be  present  at,  or  soon  after,  birth  and  be  reduced  by  the  rearrangement 
which  takes  place  among  the  abdominal  and  pelvic  viscera  in  the  first 
year  of  life.  If  it  persists,  it  may  give  rise  in  later  life  to  dysmenor- 
rhoea,  perhaps  also  to  sterility. 


CHAPTER  XXXII 

NEOPLASMS  OF   THE  FALLOPIAN  TUBES 

Benign  neoplasms:  papillomata ;  cj'stomata;  lipomata;  fibromyomata — Malignant 
neoplasms:  carcinomata;  sarcomata. 

Adventitious  growths  of  the  Fallopian  tubes  are  of  comparatively 
rare  occurrence  and  of  but  relatively  small  clinical  importance.  Little 
has  been  written  upon  this  subject,  and,  for  our  present  knowledge, 
we  are  indebted  chiefly  to  Bland  Sutton,  Orthmann,  Clark,  and  Doleris. 
A  systematic  study  of  these  growths  must  be  based  upon  the  fact  em- 
phasized by  Coe  that  the  Fallopian  tubes  are  but  extensions  of  the 
uterus  itself  and  contain  the  same  histologic  elements;  and  that  they 
are,  therefore,  liable  in  a  certain  degree  to  the  same  neoplastic  changes. 
Growths  originating  in  these  structures,  like  those  originating  else- 
where, are  divisible  into  benign  and  malignant. 

The  benign  neoplasms  of  the  Fallopian  tubes,  so  far  as  described, 
are  (a)  pajDillomata,  (h)  cystomata,  (c)  lipomata,  (d)  fibromyomata. 

Papillomata  occurring  in  the  Fallopian  tubes  have  been  carefully 
studied  b}-  Clark.  Doran  was  the  first  to  call  attention  to  the  subject 
which  has  been  carefully  elaborated  by  Sanger  and  Barth.  Bland 
Sutton,  who  has  reported  two  cases,  has  demonstrated  the  fact  that  the 
mucous  membrane  of  the  Fallopian  tubes  contains  glands  the  adeno- 
matous tissue  of  which  may  become  the  starting  point  of  true  homolo- 
gous papillomata.  This  theory,  however,  has  been  rejected  by  Sanger 
and  Barth.  Papillomata  in  the  tubes  manifest  themselves  by  the  de- 
velopment of  a  tumour,  which  is  generally  the  first  symptom  to  attract 
the  patient's  attention.  This  growth  becomes  painful  and  may  confine 
the  patient  to  bed  with  repeated  attacks  of  peritonitis.  The  tumour 
may  be  globular,  elastic,  and  fiuctuating,  and  may  possess  a  varying 
degree  of  mobility.  It  may  be  small  or  it  may  be  large  enough  to  pro- 
duce lateral  displacements  of  the  uterus  with  obscuration  of  its  fundus. 
In  Slansky's  case,  which  comprised  the  basis  of  Clark's  article,  the 
tumour  was  about  half  the  size  of  a  man's  head,  presenting  at  one  spot 
an  amputated  surface  about  4  centimetres  square,  at  one  point  of 
which  was  a  short  pedicle  having  the  appearance  of  the  enlarged 
uterine  end  of  the  Fallopian  tube;  close  to  the  point  of  amputation 
was  an  irregularly  torn  opening  through  which  the  contents  of  the 
cyst  had  escaped.  The  external  surface  of  the  tumour  was  smooth, 
containing  a  few  large  dilated  blood  vessels  and  showing  in  the  deeper 
478 


NEOPLASMS  OP  THE  FALLOPIAN  TUBES         479 

layers  occasional  necrotic  areas.  The  internal  surface  was  covered  witK 
a  thick  papillary  growth,  consisting  of  multiple  funguslike  excres- 
cences which,  in  some  areas,  were  massed  together  in  thick,  dense 
clumps,  presenting  a  typical  cauliflower  appearance.  The  papillae 
varied  from  delicate  flmbrite  to  large,  fusiform  projections  containing 
small  cysts.  There  were  occasional  areas  devoid  of  excrescences.  The 
morbid  histology  of  tubal  papillomata  is  accurately  described  by  Clark 
(Bulletin  of  the  Johns  Hopkins  Hospital),  who  found  that  sections 
through  the  circular  folds  showed  a  greatly  attenuated  cyst  wall  meas- 
uring only  0.05  to  0.1  centimetre  in  thickness.  Peritoneum,  circular 
muscle  fibres,  a  thin  stratum  of  connective  tissue,  longitudinal  muscle 
fibres,  followed  by  a  denser  layer  of  connective  tissue  upon  which  rested 
one  layer  of  columnar  epithelium,  arranged  in  regular  order,  were  shown 
upon  the  slide  in  consecutive  striae.  Except  in  the  baylike  projections- 
between  the  folds,  the  epithelium  was  nonciliated,  and,  even  in  these 
spaces,  the  ciliated  cells  were  only  rarely  found.  Clark's  further  de- 
scription of  the  microscopic  appearances  is  as  follows: 

"  Numerous  large  dilated  blood  vessels  occupy  the  connective-tissue 
layer  beneath  the  epithelium.  The  folds  of  the  Fallopian  tube,  as  such, 
are  no  longer  present,  but  are  represented  by  sessile  and  pedunculated 
papillary  growths. 

"  The  low  sessile  projections  are  composed  of  dense  connective  tis- 
sue, like  that  seen  in  chronic  inflammation  of  the  tube,  whose  cells  ex- 
tend at  right  angles  from  the  underlying  circular  fibres,  forming  warty 
prominences  clad  with  one  layer  of  columnar  epithelium  which  gradu- 
ally shades  off  into  the  low  columnar  and  cuboidal  variety  as  the  domes 
of  the  projections  are  reached.  Besides  the  sessile  excrescences  there 
are  a  few  long,  slender  processes  to  which  are  attached  daughter  off- 
shoots. The  main  stem  in  all  instances  contains  large  dilated  blood 
vessels.  The  connective  tissue  forming  the  stroma  of  these  papillse 
shows  a  marked  variation  in  its  structure  in  different  areas.  At  the 
bases  of  the  papillge  the  cells  are  closely  crowded  together  and  contain 
deeply-staining  spindle-shaped  nuclei.  This  appearance  is  maintained 
until  the  apices  or  domes  of  the  growths  are  approached,  when  the 
cells  gradually  become  hyaline,  and  in  turn  shade  off  into  a  pure  mucoid 
degeneration. 

"  Sections  from  the  thicker  portions  of  the  cyst  wall  (0.5  centimetre 
thick)  show  unstriated  muscle  fibres  scattered  very  sparsely  among 
the  connective-tissue  fibres  which  make  up  the  chief  part  of  the  sec- 
tion. The  internal  surface  of  the  cyst  wall  is  covered  with  innumer- 
able, vigorous  growing  papillomata,  whose  main  stems  extend  far  out 
into  the  lumen  of  the  cyst,  forming  the  most  complicated,  coral-like 
systems.  The  offshoots  have,  in  many  instances,  coalesced,  forming 
spaces  which  contain  small  papillary  growths. 

"  In  some  instances  the  main  stems  have  become  adherent  to  each 
other,  inclosing  much  larger  glandlike  spaces.  The  mucoid  degenera- 
tion noted  above  is  even  more  marked  here,  and  in  the  large  fusiform 


480  "      A  TEXT-BOOK   OP   GYNECOLOGY 

ends  of  some  of  the  branches  the  entire  stroma  has  undergone  this 
transformation^  giving  the  cystic  appearance  noted  in  the  macroscopical 
description.  Hemorrhage  has  occurred  into  some  of  these  spaces  con- 
taining the  mucous  tissue^  leaving  a  granular  debris  which  stains  a 
hright  yellow  by  Van  Gieson's  method. 

"  The  ends  undergoing  degeneration  are  covered  by  one  layer  of 
shrunken  cuboidal  epithelium,  which  rests  upon  a  thin  layer  of  hyaline 
connective  tissue.  Besides  the  cystic  spaces  formed  by  the  fusion  of 
the  papillomata,  others  are  found  occupying  a  deeper  portion  of  the 
cyst  wall,  lined  by  cuboidal  epithelium  and  surrounded  by  a  dense  con- 
nective-tissue stroma  like  those  seen  in  '  sacto-saljainx  jDseudo-follicu- 
laris.'    (Martin.) 

"  In  one  of  these  spaces  a  small  papilloma  is  seen  in  process  of 
formation.  The  single  layer  of  cuboidal  epithelium  lining  the  cavity 
forms  an  uninterrupted  line,  except  at  one  point,  where  it  assumes  a 
columnar  shape  and  becomes  heaped  upon  a  delicate  connective-tissue 
papilla  projecting  from  the  main  stroma." 

The  symptoms  of  papillomata  of  the  ovary  are  simply  those  of  an 
intrapelvic  tumour.  They  are  painful  but  not  more  so  than  certain 
dermoids.  Their  tendency  to  rupture  of  the  tube  or  cajjsule  in  which 
they  develop,  results  in  the  escape  of  blood  and  of  the  products  of 
degeneration  into  the  peritoneal  cavity,  causing  inflammation  of  that 
membrane.  In  none  of  the  cases  so  far  reported,  only  six  in  num- 
her,  has  a  diagnosis  been  made  before  operation.  The  treatment  con- 
sists in  the  removal  of  the  tumour  by  abdominal  section.  In  view  of 
the  fact  emphasized  by  Williams  that  all  papillomatous  growths  have 
a  tendency  to  undergo  malignant  degeneration,  this  form  of  neoplasm, 
rare  as  it  is,  furnishes  another  reason  for  prompt  intervention  in  the 
presence  of  a  pelvic  tumour  of  undetermined  character. 

Cystomata  of  the  Fallopian  tubes  are  generally  of  rare  occurrence, 
■of  insignificant  size,  and  of  but  little  clinical  interest.  They  may 
originate  either  within  the  serous  coat  or  the  muscularis,  although 
their  favourite  site  of  development  is  from  the  vestibular  mucosa.  It 
is  probable  that  they  are  inflammatory  products,  in  the  sense  that 
mucous  follicles  have  become  occluded  and  thus  converted  into  re- 
tention cysts.  Sutton  has  reported  a  large  cyst  which  developed  in 
the  muscularis  and  attained  the  size  of  a  walnut,  the  probable  origin 
of  which  was  similar  to  that  observed  by  Kiwisch  in  the  submucosa, 
and  which  was  demonstrably  of  inflammatory  origin.  A.  Martin  has 
published  an  interesting  picture  showing  the  cysts  and  other  growths 
that  develop  about  the  vestibule  (Fig.  209). 

Lipomata  can  hardly  be  spoken  of  in  the  plural,  when  indicating 
these  growths  as  they  develop  in  the  Fallopian  tubes.  Their  existence, 
so  far  as  available  records  indicate,  depends  upon  the  report  of  a 
single  case  by  Eokitansky.  The  neoplasm  in  that  case  was  about  the 
size  of  a  walnut.  The  condition  is  symptomless  and  without  clinical 
interest. 


NEOPLASMS  OF  THE  FALLOPIAN  TUBES 


481 


Fibromyomata  may  develop  from  the  muscularis  of  the  tube. 
Hypertrophy  and  hyperplasia  of  this  tunic  are  not  infrequent  sequelae 
of  salpingitis,  and  have  been  noted  by  Sutton  as  accompaniments  of 
fibroid  degeneration  of  the  uterus.    These  areas  of  hyperplasia  may  be 


Fig.  209. — "  A.  Martin  has  published  an  interesting  picture  showing  cysts  and  other  growths 
that  develop  about  the  vestibule." — Eeed  (page  480). 

more  or  less  limited  by  bands  of  constriction  which  give  to  them  the 
appearance  of  myomatous  degeneration.  As  pointed  out  by  Coe,  how- 
ever, they  are  not  true  neoplasms.  These  latter  are  relatively  of  smaller 
size,  rarely  more  than  from  1  to  2  centimetres  in  diameter,  although 
Speth's  case,  which  is  accepted  as  reliable,  was  about  4  centimetres  in 
diameter.  These  nodules  may  be  interstitial,  but  are  generally  sub- 
serous and  pedunculated.  They  abound  more  in  muscular  than  fibrous 
tissue.  They  belong  to  the  curiosities  of  pathology,  and  are  rarely 
productive  of  symptoms. 

Malignant  neoplasms  of  the  Fallopian  tubes  are  (a)  carcinomata 
and  (b)  sarcomata. 

Carcinomata  occur  in  the  tubes  usually  as  the  result  of  extension 
of  the  disease  from  the  corporeal  endometrium.  It  has  been  asserted 
that  metastasis  of  carcinoma  from  the  uterus  to  the  tubes  is  of  very 
rare  occurrence.  Kiwisch  found  carcinoma  of  the  tube  only  18  times 
in  73  cases  of  cancer  of  the  uterus,  and  Dittrich  in  only  4  cases  out 
of  94  of  general  carcinomatosis.  Orthmann,  in  a  communication  on 
this  sul)ject  to  the  Gynecological  Society  of  Berlin  (Centralblatt  filr 
GyndJcologie),  stated  that  a  careful  research  of  the  literature  of  the 
subject  yielded  accurate  descriptions  of  only  13  cases,  in  9  of  which 
the  uterus  and  in  4  the  ovaries  wore  primarily  affected.     The  disease 


482  '       A   TEXT-BOOK  OF   GYNECOLOGY 

may  occur  primarily  in  the  tubes.  This  was  true  in  1  out  of  3  cases, 
occurring  in  Martin's  clinic.  The  fact  that  metastasis  to  the  tubes 
is  of  such  rare  occurrence  is  explained^  according  to  Olshausen,  by  the 
distribution  of  the  lymphatics,  which  do  not  favour  the  migration  of 
morbific  elements  from  either  the  ovaries  or  the  uterus  to  the  oviducts. 
Sarcomata  are  of  infrequent  occurrence  in  the  Fallopian  tubes. 
The  reports  of  the  few  cases  which  have  been  recorded  raise  some  doubt 
as  to  the  exact  character  of  the  neoplasm.  The  histologic  elements 
are  usually  so  diverse  that  the  growth  itself  is  hardly  susceptible  of 
exact  classification.  The  preponderance  of  connective-tissue  elements, 
occurring  in  connection  with  other  forms  of  cell  growth,  has  gen- 
erall}^  resulted  in  the  designation  of  the  tumour  as  a  sarcoma,  or,  more 
properly,  a  myxosarcoma.  These  tumours  rarely  attain  the  size 
reached  by  true  sarcomata  in  other  localities.  Their  growth  is  gener- 
ally more  rapid  than  that  of  benign  neoplasms,  or,  indeed,  of  the 
papillomata,  the  benignity  of  which  is  open  to  suspicion.  Their  symp- 
tomatology is  simply  that  of  a  pelvic  tumour,  the  existence  of  which 
should  always  be  regarded  as  an  indication  for  an  incision  undertaken 
for  diagnostic  purposes.  In  this  suggestion  lies  the  correct  indication 
for  treatment  of  these  cases. 


CHAPTEE  XXXIII 

INFECTIONS   AND   INFLAMMATIONS   OF   THE 
FALLOPIAN    TUBES 

Infections  in  general — Bacteria  of  the  Fallopian  tubes  in  health — Bacteria  of  the 
Fallopian  tubes  in  disease — Relations  of  infections  to  inflammations  of  the 
tubes — Catarrhal  salpingitis — Morbid  histology  of  salpingitis:  (a)  acute,  (b) 
chronic — Hydrosalpinx — Hematosalpinx — Pyosalpinx — Symptoms  and  diag- 
nosis of  salpingitis. 

Infections  of  the  Fallopian  Tubes. — The  Fallopian  tubes  are  fre- 
quently the  seat  of  infection.  It  may  be  said  that,  aside  from  neo- 
plasms, which  are  rare,  and  malformations,  which  are  still  more  rare, 
infections  of  the  Fallopian  tube  cause,  either  directly  or  indirectly, 
practically  all  the  diseased  conditions  which  in  those  structures  demand 
the  attention  of  the  practitioner.  It  is  true  that  many  of  the  in- 
fections of  the  Fallopian  tube  can  not  be  distinguished  from  each 
other  by  present  clinical  methods;  this  fact,  however,  must  not  be 
accepted  as  a  final  barrier  to  either  the  present  consideration  or  the 
future  investigation  of  these  conditions  from  the  standpoint  of  their 
causation.  The  constant  improvement  in  methods  of  investigation  is 
resulting  in  the  progressive  revelation  of  new  and  important  facts 
relative  to  the  bacteriology  and  the  histo-pathology  of  the  Fallopian 
tubes,  as  of  other  structures  of  the  body.  While  this  fact  is  recog- 
nised and  acted  upon,  the  outlook  must  be  accepted  as  promising. 
Thus,  Eeymond  {Annals  of  Surgery)  found  streptococci  in  a  number 
of  cases  which  a  few  years  previously  would  have  been  considered 
sterile  salpingitis,  but  in  which,  by  means  of  improved  methods,  the 
micro-organisms  were  discovered.  Practically  all  the  progress  which 
has  been  made  in  this  department  has  been  realized,  step  by  step,  by 
such  painstaking  investigations.  The  point  at  which  we  have  arrived, 
justifies  the  consideration  of  all  inflammatory  diseases  of  the  Fallopian 
tubes  as  of  infectious  origin,  although  the  dominant  micro-organism 
upon  which  the  infection  depends,  can  not  be  isolated  in  all  cases.  A 
systematic  consideration  of  the  subject  must  take  into  account  (a)  the 
bacteria  of  the  Fallopian  tube  in  health;  {!))  the  bacteria  of  the  Fal- 
lopian tube  in  disease;  (c)  the  general  pathology  of  inflammation  of 
the  tubes  induced  by  infections  in  general;  {d)  individual  infections; 
find  ((')  treatment. 

483 


484  A  TEXT-BOOK  OP   GYNECOLOGY 

The  bacteria  of  the  Fallopian  tubes  in  health  have  been  investigated 
by  Sinclair,  who  points  out  the  fact  that,  from  the  bacteriological  point 
of  view,  it  is  well  to  keep  in  mind  that  the  Fallopian  tube  has  two 
openings,  one  extremely  narrow,  connecting  it  with  the  cavity  of  the 
uterus,  and  the  other,  the  wide  abdominal  orifice  connecting  it  with 
the  peritoneal  cavity. 

Invasion  of  the  tube  by  bacteria  may  occur  from  either  end,  or 
through  its  walls  under  special  conditions.  The  cavity  of  the  uterus 
in  health  is  free  from  germs  and  so  is  the  peritoneal  cavity.  Inva- 
sion through  the  walls  of  the  tube  only  occurs  in  adhesion  to  the  intes- 
tine or  from  bacterial  disease  in  the  pelvis.  Consequently  in  a  state 
of  health  the  Falloj^ian  tube  is  entirely  free  from  germs. 

Witte  examined  freshly  extirpated  and  apparently  healthy  tubes  in 
11  cases.  In  9  cases,  the  cultivation  remained  absolutely  sterile.  In 
one  of  the  remaining  cases  he  found  both  the  staphylococcus  and  the 
streptococcus,  in  the  other  only  a  sparse  growth  of  the  staphylococ- 
cus. The  corresponding  uterus  in  each  case  was  examined  at  the 
same  time,  and,  in  the  cervical  canal  of  the  first,  the  streptococcus 
and  staphylococcus  were  found.  In  the  second  uterus,  the  staphylo- 
coccus was  discovered  in  the  cavity  of  the  body.  In  spite  of  the 
obvious  cause  of  the  presence  of  bacteria  in  the  tubes,  Witte  drew 
the  general  inference  that  the  healthy  tubes  might  contain  micro- 
organisms. 

Winter  examined  40  tubes  which  had  just  been  obtained  by  opera- 
tion. He  emj^loyed  the  usual  methods  of  cultivation  in  searching  for 
bacteria,  and,  although  there  were  a  few  exceptions  of  which  he  con- 
sidered the  explanation  satisfactory,  he  concluded  that  the  healthy 
tube  was  free  from  bacteria. 

Menge  examined  83  tubes  obtained  from  50  women  operated  upon 
for  various  reasons.  Exact  examination  by  the  microscope  and  by 
cultivation  experiments  in  various  ways  may  be  assumed.  He  came 
to  the  same  conclusion  as  Winter,  namely,  that  "  the  normal  tube 
is  always  germ-free." 

It  is  possible  that  the  tubercle  bacillus  may  be  found  in  or  about 
the  apparently  healthy  tube  in  very  minute  areas  of  infection,  but  it 
is  a  circumstance  which  must  be  extremely  rare,  and  not  to  be  dis- 
cussed here  without  entire  disregard  of  proportion.  The  pathogenic 
bacteria  of  every  other  sort  produce  marked  tissue  changes  immediately 
after  invading  the  tube. 

The  bacteria  of  the  Fallopian  tubes  in  disease  are  of  extreme  im- 
portance, for,  as  already  stated,  and  as  emphasized  by  Sinclair,  among 
the  diseases  of  the  tubes  which  must  be  referred  to  bacterial  invasion, 
we  find  all,  almost  without  exception,  with  which  we  have  to  deal  in 
gynecological  practice. 

For  the  production  of  a  serous  collection  in  the  Fallopian  tube 
(hydrosalpinx),  two  things  are  necessary:  on  the  positive  side,  the  oc- 
currence more  or  less  remotely  of  sufficient  perisalpingitis  to  close  the 


INFECTIONS  AND   INFLAMMATIONS  OP  FALLOPIAN   TUBES    485 

abdominal  orifice;  and  on  the  negative,  the  absence  of  such  an  amount 
of  bacterial  infection  as  will  permit  the  fluid  distending  the  tube  to 
remain  clear.  The  most  common  form  of  hydrosalpinx,  that  with  the 
walls  thin  and  translucent  owing  to  the  great  distention  of  the  tube, 
usually  shows  signs  of  pre-existing  inflammation  in  addition  to  the 
sealing  up  of  the  ostium  abdominale;  but  it  is  hardly  conceivable  that 
any  virulent  bacterial  infection  at  any  previous  time  could  leave  so  few 
traces  of  its  existence. 

In  the  form  of  hydrosalpinx,  where  the  walls  are  thick  and  com- 
paratively hard,  the  anatomical  changes  may  be,  and  most  likely  are, 
produced  by  the  work  of  pathogenic  bacteria  of  such  a  modified  viru- 
lence, or  in  such  small  quantity,  as  not  to  produce  pyosalpinx. 

To  leave  theory  and  come  to  the  results  of  the  comparatively  small 
amount  of  work  that  has  been  done  in  the  bacteriology  of  hydro- 
salpinx; the  examinations  made  by  Menge  on  20  cases  of  hydrosal- 
pinx and  3  of  hematosalpinx  gave  an  absolutel}^  negative  result.  The 
usual  care  was  exercised,  and  a  great  variety  of  cultivation  methods  were 
adopted,  including  the  methods  and  media  employed  in  the  search  for 
the  bacillus  tuberculosis,  and  yet  the  results  indicated  the  entire  ab- 
sence of  any  germs  which  could  be  seen  with  the  microscope  or  culti- 
vated by  any  of  our  known  methods. 

It  is  interesting  to  notice  that  the  conservative  method  of  dealing 
with  hydrosalpinx  by  simple  incision,  or  its  equivalent,  has  received 
post-factum  justification  from  the  bacteriologists. 

The  bacteria  of  purulent  inflammations  (pyosalpinx)  are  beginning 
to  be  better  understood.  It  is  only  a  short  time  since  we  hardly  knew 
of  the  existence  of  diseases  of  the  Fallopian  tubes.  In  the  last  decade 
and  a  little  more,  they  have  been  more  exactly  and  effectively  studied, 
owing  to  the  wealth  of  material  obtained  by  the  introduction  of  radical 
surgical  treatment.  The  tendency  now  is  to  set  down  all  the  more 
severe  forms  to  bacterial  invasion,  especially  by  the  gonococcus  and 
the  pathogenic  bacteria,  which  produce  endometritis  in  childbed.  Ever 
since  Westermark,  in  1886,  announced  the  discovery  of  the  gonococcus 
in  the  pus  of  a  pyosalpinx,  innumerable  investigations  to  prove  or 
disprove  the  bacterial  origin  of  tubal  disease  have  been  undertaken, 
and  the  contributions  to  the  bacteriology  of  the  subject  have  been 
voluminous  in  the  extreme,  and,  as  usual,  many-voiced  and  often  con- 
tradictory. In  addition  to  the  study  of  the  gonococcus  and  other 
pathogenic  micro-organisms,  many  observations,  both  clinical  and 
bacteriological,  have  been  made  upon  the  phenomena  of  tuberculosis 
of  the  tubes  and  ovaries  with  an  exactitude  unknown  before  the  era 
of  gynecological  surgery. 

The  conclusion  which  receives  practically  unanimous  support  is, 
that  the  gonococcus  is  hy  far  the  most  frequent  cause  of  purulent  sal- 
piru/ilis. 

Wer-thcirn,  who  was  among  the  first  to  publish  any  considerable 
I!  II  III  her'  of  (;xa(;ily  o])S(;rv(!d  cases  froiri  the  bactet'iological  standpoint. 


486  A   TEXT-BOOK   OF   GYNECOLOGY 

found  that  ont  of  2-i  cases,  the  jDroducts  of  inflammation  were  sterile  in 
6;  the  gonocoecus  was  found  in  16;  in  1  case  the  streptococcus  was 
found,  and  in  1,  the  pus  contained  a  bacterium  which  he  could  not 
identify.  Wertheim,  like  most  observers,  found  that  the  gonocoecus 
held  the  first  place  as  the  j)roducer  of  pyosalpinx,  and  that  other  bac- 
teria were  the  agents  only  occasionally.  He  did  not  see  reason  to 
believe  that  the  gonocoecus  prepared  the  way  for  secondary  invasion 
by  pyogenic  organisms.  As  a  rule,  when  the  gonocoecus  is  present  no 
other  bacteria  are  found. 

Menge's  results  in  his  first  series  of  cases  in  which  the  Fallopian 
tubes  were  the  seat  of  inflammation,  were  much  the  same  as  Wert- 
heim's.  The  gonocoecus  was  the  most  common  cause  of  the  dis- 
ease, but  the  streptococcus  and  staphylococcus  were  occasionally  found, 
and,  in  a  very  few  cases,  the  Diplococcus  pnewnonice  and  the  Bacillus 
tuberculosis.  In  the  great  majority  of  cases,  the  pus  in  pyosalpinx 
sacs  was  sterile,  and  a  mixed  infection  was  found  to  exist  in  the 
tubes  only  when  they  were  adherent  to  other  viscera.  Adhesion  to  the 
intestine  owing  to  bacterial  inflammation  appears  to  lead  to  the  pas- 
sage of  bacteria  bv  softening  of  the  tissues,  or  by  actual  communication 
through  an  orifice  formed  by  destruction  of  tissues.  The  other,  more 
ordinary,  wa3'S  in  which  bacteria  gain  access  are  well  known.  They  are 
chiefly  by  extension  of  endometritis  of  bacterial  origin  upward,  or  by 
invasion  from  above,  usually  by  the  tubercle  bacillus. 

The  war  of  words  and  opinions  regarding  "  mixed  infection  "  has 
been  waged  chiefly  around  pyosalpinx  and  the  relations  of  the  gono- 
coecus to  other  pyogenic  organisms.  It  is  agreed  that  the  gonocoecus 
does  not  incline  toward  symbiosis,  but  there  can  be  no  doubt  that  it  is 
found  occasionally  in  company  with  saprophytes  and  pathogenic  organ- 
isms. The  discussion  has  some  bearings  on  practical  gynecology,  e.  g., 
there  can  be  no  doubt  that  gonorrhoea  may  extend  to  Fallopian  tubes 
alread}^  invaded  by  the  slowly  acting  Bacillus  tuberculosis;  and  the 
clinical  facts,  as  well  as  bacteriological  investigations,  show  that  an 
acute  puerperal  endometritis,  primarily  due  to  the  streptococcous  infec- 
tion, may  be  influenced  for  the  worse  by  the  spread  of  gonococcous  in- 
fection from  the  cervix.  Isolated  observations  like  that  of  Kronig, 
in  which  a  gonorrhoeal  endometritis  was  cured  through  a  puerperal 
infection  by  the  streptococcus,  and  a  vulvo-vaginitis  by  an  attack  of 
erysipelas  in  the  neighbourhood  of  the  parts,  are  as  yet  mere  riddles 
with  no  place  in  any  ordered  set  of  well-supported  opinions.  Upon 
the  whole,  however,  it  may  be  confidently  alleged  that  the  subject  of 
"  mixed  infection  "  is  of  interest  almost  entirely  for  the  bacteriologist 
as  distinguished  from  the  gynecologist. 

The  bacteriology  of  chronic  salpingitis  is  of  considerable  interest.  In 
cases  operated  upon,  the  tissues  are  often  so  much  hypertrophied  as  to 
give  the  impression,  at  the  time  of  pre-operation  diagnosis,  that  a 
tumour,  or  even  a  cystic  tumour,  exists.  The  disease  is  usually  of 
bacterial  origin,  often  set  up  by  the  gonocoecus,  and,  like  endometritis, 


INFECTIONS  AND  INFLAMMATIONS   OF   FALLOPIAN  TUBES    487 

'Carrying  infiltration  and  hypertrophy  in  its  train;  yet  examination  of 
the  secretion  and  the  tissues  in  chronic  salpingitis  hardly  ever  shows 
the  presence  of  bacteria. 

With  regard  to  purulent  salpingitis  with  or  without  pyosalpinx  for- 
mation, Menge's  examinations  and  his  results  appear  to  state  the  whole 
•case.  His  material  consisted  of  the  tubes  from  122  cases  of  purulent 
salpingitis,  to  part  of  which  reference  has  already  been  made.  The 
secretion  and  the  tissues  of  the  tubes  w^ere  examined,  and  cultivation 
•experiments  were  carried  out  on  a  large  scale.  Shortly  stated,  the 
results  were  the  following: 

In  122  cases,  the  contents  of  the  tubes  were  free  from  bacteria  75 
times;  they  contained  bacteria  47  times.  In  28  cases,  the  gonococcus 
was  found  alone;  in  9,  the  tubercle  bacillus  alone;  once,  a  pyogenic 
.staphylococcus  alone;  once,  the  colon  bacillus  alone;  once,  an  anaerobic 
diplococcus  alone.  In  47  cases,  then,  in  which  bacteria  were  dis- 
covered, the  culture  was  pure  in  44  and  mixed  in  3.  The  presence  of 
the  gonococcus  was  ascertained  partly  by  cultivation,  and  partly  by 
jaicroscopic  examination,  identifying  the  organism  by  the  use  of  Gram's 
method. 

Menge  gives  numerous  details  of  anatomical  changes  which  are  of 
interest  from  other  than  the  bacteriological  point  of  view.  One  ob- 
servation will  be  borne  out  by  all  who  have  had  any  considerable 
experience  in  the  surgery  of  the  parts,  that  it  is  impossible  during 
operation  to  distinguish  a  pyosalpinx  due  to  tubercle  from  one  due 
to  other  causes.  The  discussion  of  primary  and  secondary  tubercle 
of  the  female  sexual  organs  in  general,  and  of  the  tubes  in  particular, 
hardly  belongs  to  the  present  subject.  It  is,  however,  a  striking  re- 
sult of  bacteriological  examination  of  cases  actually  operated  upon  for 
tubal  disease,  that  nearly  10  per  cent  were  found  to  depend  upon  the 
tubercle  bacillus  alone  for  the  anatomical  and  other  changes  which 
gave  rise  to  the  symptoms.  The  tubercle  bacillus  appears,  therefore, 
to  play  a  more  important  part  as  a  parasite  of  the  tubes  than  the 
streptococcus  and  staphylococcus.  The  Bacterium  coli  commune  and 
the  anaerobic  pathogenic  bacteria  are  still  less  important. 

Perhaps,  says  Sinclair,  sufficient  attention  has  not  been  called  to 
the  fact  that,  in  the  great  majority  of  cases  of  pyosalpinx,  the  secretion 
and  tissues  of  the  walls  are  found  to  be  germ-free.  This  must  imply 
that  the  bacteria  have  died  out  and  that  the  pus  is  consequently  sterile. 
It  is  to  this  fact,  almost  certainly,  that  we  owe  the  comparative  innocu- 
ousness  of  pus  spilled  into  the  pelvic  cavity  during  operations  on  the 
pus  tubes.  It  is  probably  in  these  obsolete  cases,  when  no  secondary 
invasion  has  taken  place,  that  the  symptom  of  fever  does  not  exist. 
The  bacteria  have  ceased  to  produce  toxines.  But  this  subject,  lying 
between  bacteriology  and  clinical  gynecology,  is  still  wrapped  in 
mystery. 

The  relations  of  infections  to  inflammations  of  the  tubes  are  demon- 
strable. 


488  A   TEXT-BOOK  OF   GYNECOLOGY 

Infections  of  the  Fallopian  tubes  result  in  inflammation  of  those 
structures.  In  the  earlier  classification  of  inflammatory  diseases  of 
the  oviducts,  the  gross,  or  macroscopic  appearance,  of  the  tubal  en- 
largements, together  with  their  contents,  was  taken  as  the  guide  for 
nomenclature.  Thus  the  terms  hydrosalpinx  and  pyosalpinx  signify,  in 
the  one  instance  a  watery  or  dropsical,  and  in  the  other  a  purulent,  col- 
lection within  the  tube,  without  regard  to  the  causation  or  pathology  of 
the  disease. 

This  classification  still  prevails,  and  quite  justly  so,  for  laboratory 
methods  have  not  as  yet  led  to  a  more  accurate  or  specific  nosology 
capable  of  being  successfully  adapted  to  clinical  diagnosis. 

Without  question,  the  classification  of  diseases  according  to  their 
etiology  would  be  preferable,  on  account  of  its  greater  scientific  accu- 
racy, but,  so  far,  neither  a  careful  bacteriological  examination,  nor 
microscopical  sections,  are  sufiicient  to  reveal  the  primary  infecting  or 
exciting  agent  in  a  majority  of  cases. 

Tuberculosis  is  an  exception  to  this  rule,  for  its  microscopical 
lesions  are  so  characteristic  as  to  be  quite  pathognomonic;  but  even 
this  disease  is  frequently  not  recognised  clinically  at  the  time  of 
operation.  (See  Tuberculosis  of  the  Fallopian  Tubes.)  Gonococcous 
and  streptococcous  infections  are  likewise  susceptible,  although  in  a 
less  definite  degree,  of  individual  study;  but  even  these  micro-organ- 
isms, while  exercising  a  dominant  and  determining  influence  over  the 
course  of  subsequent  morbid  events,  ordinarily  occur  in  company  with 
other  pathogenic  bacteria.  The  closer  study  of  the  causes  of  inflam- 
mation in  recent  years,  says  Clark,  has  established  the  fact  that  it 
is  never  an  idiopathic  process,  for  it  can  not  originate  de  novo.  Of  late, 
he  adds,  it  has  also  been  conclusively  demonstrated  that  the  mechanical 
and  chemical  causes  (exclusive  of  bacterial  toxines)  seldom  play  a 
causative  role,  and  that  the  prime  factors  in  the  production  of  sur- 
gical inflammations  are  of  bacterial  origin.  To  classify  accurately 
inflammatory  diseases  according  to  the  speciflc  organism  which  pro- 
duced them,  would  be  a  scientific  ideal;  but  as  this,  with  the  exceptions 
already  noted,  is  not  at  present  practicable,  the  older  nomenclature  to 
which  we  have  become  accustomed  through  long  usage  should  be  re- 
tained, until  after  the  discovery  of  more  positive  means  by  which  the 
different  varieties  of  inflammation,  classified  according  to  their  causa- 
tion, may  be  further  distingushed  from  each  other.  Concerning  the 
significance  of  names  in  these  various  conditions,  there  has  been  con- 
siderable discussion,  but  as  this  is  not  of  great  moment,  for  the  obvious 
reasons  just  pointed  out,  the  usual  terms  will  be  employed;  when 
necessary,  the  newer  terms  will  be  indicated  as  synonyms  in  the  con- 
sideration of  the  general  morbid  changes  that  are  induced.  In  the 
present  state  of  our  knowledge,  it  is  best  to  consider  infections  of  the 
Fallopian  tubes  from  (a)  the  standpoint  of  morbid  histology,  and,  (b)  as 
far  as  possible,  from  the  standpoint  of  the  individual  infectious 
element. 


INFECTIONS   AND   INFLAMMATIONS   OF   FALLOPIAN   TUBES    489 

Catarrhal  Salpingitis  (Salpingitis  C atarrhalis) . — Before  taking  up 
the  morbid  conditions  of  the  Fallopian  tubes,  it  may  be  well  to  recall 
quite  briefly  the  essential  points  in  their  normal  anatomy.  As  each 
tube  emerges  from  the  cornu  uteri  it  is  of  exceedingly  small  calibre, 
its  lumen  barely  admitting  a  fine  bristle.  From  this  point  (ostium 
uterinum)  it  continues  narrow  for  at  least  one  third  of  its  length,  then 
gradually  widens  into  a  trumpet-shaped  termination  which  again  con- 
tracts somewhat  at  the  abdominal  opening  (ostium  abdominale).  JSTor- 
mally,  the  tube  runs  in  almost  a  straight  course  outward  for  half  its 
length,  then  curves  gently  downward  and  dips  into  the  pelvic  cavity 
posteriorly  to  the  broad  ligament.  Its  mesentery  is  formed  by  two  folds 
of  the  broad  ligament  within  which  it  is  situated.  The  three  layers 
of  the  tube  consist  of  the  enveloping  peritoneum,  muscle  (longitudinal 
and  circular),  and  mucosa.  As  the  mucosa  is  the  portion  of  the  tube 
primarily  affected  in  endosalpingitis,  the  earliest  stage  of  salpingitis, 
a  more  minute  consideration  of  its  finer  histology  will  not  be  out  of 
place. 

This  coat  is  continuous  with  the  lining  membrane  of  the  uterus, 
but,  unlike  it,  has  no  glands,  although  the  depressions  between  the 
folds  are  so  strikingly  similar  as  to  have  caused  Hennig,  and  later 
Bland  Sutton,  to  describe  them  as  true  adenoid  structures.  The  gen- 
eral consensus  of  opinion  among  the  best  histologists  of  the  present 
time  is  against  this  acceptation,  and  the  mucosa  may  therefore  be  con- 
sidered as  a  simple  nonglandular  tissue.  The  interstitial,  or  uterine, 
portion  of  the  tube  resembles  in  shape  the  letter  H,  and  is  lined  by 
one  layer  of  columnar  ciliated  epithelium;  in  the  extra-uterine  part  of 
the  tube,  the  mucosa  assumes  a  rugous  appearance,  being  thrown  up 
into  exquisite  villous  or  coral-like  projections.  The  connective-tissue 
stroma  contains  delicate  vascular  twigs  which  run  out  at  right  angles 
from  the  circular  blood  vessels  of  the  tube,  and  terminate  as  a  rich 
anastomosis  beneath  the  epithelium.  As  the  abdominal  end  of  the  tube 
is  approached,  the  mucosa  is  more  and  more  thrown  into  duplicatures 
until  it  terminates  in  the  fimbriated  extremities.  A  sharp  line  of  de- 
marcation indicates  the  line  of  union  between  the  mucosa  and  peri- 
toneum at  the  tips  of  the  fimbriae. 

Morbid  Histology  of  Acute  Salpingitis. — With  this  brief  resume  of 
the  essential  points  in  the  normal  histology  of  the  tube,  we  may  take 
up,  with  a  clearer  understanding,  the  various  inflammatory  changes 
that  occur  in  that  structure,  all  of  which,  regardless  of  their  mode  of 
origin,  start  first  as  a  simple  salpingitis.  This  condition  may  very 
quickly  merge  into  either  the  purulent  or  the  hemorrhagic  type,  but  so 
far  as  the  primary  pathologic  phenomena  are  concerned,  the  classic 
signs  of  inflammation — calor,  rubor,  dolor,  and  tumor — are  present,  and 
accompanying  them  are  the  vascular  injection,  the  transmigration  of 
the  leucocytes,  the  increase  in  round-celled  infiltration,  and  the  swell- 
ing of  the  epithelium,  all  characteristic  histological  changes  in  acute 
iMfl;iiiitii;ilion.     in  llic;  acute;  stage  of  iiiflainuiation,  the  noiTiial  secre- 


490  A  TEXT-BOOK  OF  GYNECOLOGY 

tion  of  the  tube  is  only  slightly  changed.  Its  consistence  is  at  first 
fluid,  later  mucoid,  the  colour  being  transparent  whitish,  milky,  or 
reddish,  according  as  it  is  mixed  with  desquamated  epithelium  and 
leucocytes  or  with  red  blood  cells.  One  of  the  most  striking  macro- 
scojDical  changes  in  the  acute  i^rocess  is  the  marked  congestion  of  the 
blood  vessels,  which  are  greatly  reddened  and  injected  and  present 
a  riblike  appearance  beneath  the  peritoneal  covering  of  the  tube.  With 
the  increase  in  length  and  thickness  of  the  tube  through  these  morbid 
changes,  the  tube  usually  becomes  kinked  and  twisted  upon  itself,  be- 
cause the  mesosalpinx  maintains,  without  any  relaxation,  its  normal 
relationship  to  the  tubes;  consequently  the  latter,  as  it  becomes  length- 
ened and  enlarged,  is  throT^m  into  a  distorted  shape.  The  fimbriated 
end  of  the  tube,  being  the  seat  of  terminal  vessels,  is  greatly  congested, 
of  a  bluish-red  colour  (cockscomb  colour),  and  a  stringy,  glairy  mucus 
is  either  seen  escaping,  or  may  be  expressed  from,  the  abdominal  orifice. 

From  the  very  beginning  of  the  inflammatory  process,  the  secretion 
of  the  tube  may  assume  a  purulent  character.  Menge  asserts  that  this 
is  the  rule  in  gonococcous  infection,  and  yet  Doderlein,  to  a  certain 
extent,  negatives  this  statement  by  the  report  of  a  case  of  double  gonor- 
rhoea! tubal  inflammation  in  which  myriads  of  gonococci  were  found; 
on  one  side  there  was  a  pyosalpinx,  while  on  the  other,  only  a  simple 
tubal  catarrh  had  occurred. 

The  mucosa  is  greatly  increased  in  thickness,  both  on  account  of 
the  hypertrophy  of  its  constituent  cells,  and  because  of  the  vascular 
congestion  of  the  villi.  At  this  stage,  a  transverse  section  of  the  tube 
presents  a  rosettelike  appearance,  the  mucosa  projecting  rather  promi- 
nently over  the  peritoneal  edges.  In  the  acute  stage  of  the  inflamma- 
tion, the  morbid  changes  may  be  conflned  entirely  to  the  epithelial 
lining,  and  the  immediately  underlying  connective-tissue  stroma, 
whence  the  term  endosalpingitis. 

So  long  as  the  inflammatory  condition  is  strictly  limited  to  the 
mucosa,  the  outward  appearance  of  the  tube,  with  the  exception  of 
the  vascular  injection  and  reddening,  presents  no  other  changes.  In- 
deed, in  the  acute  stage,  especially  when  there  is  no  increase  in  the 
tubal  secretion,  the  appearances  are  strikingly  like  those  of  the  tube 
in  its  period  of  normal  congestion  during  the  menstrual  flux. 

Notwithstanding  a  considerable  increase  in  the  secretion  of  the 
tube,  due  to  the  local  irritation  of  the  infectious  agent,  the  tubal 
epithelium  remains  intact  much  more  frequently  than  would  be  sup- 
posed. The  underlying  connective-tissue  stroma,  and  not  the  epithe- 
lium, is  the  chief  seat  of  the  initial  inflammatory  changes  in  acute 
catarrhal  salpingitis. 

On  section,  the  mucous  membrane  presents  many  folds  and  duplica- 
tures  which  form,  through  contact  of  their  free  ends,  baylike  or  loculate 
spaces.  The  stroma  cells  are  much  richer  in  nuclei  and  the  blood 
vessels  are  greatly  widened,  and  show  considerable  transmigration  of 
polynuclear  leucoc3d;es. 


INFECTIONS  AND   INFLAMMATIONS  OF   FALLOPIAN   TUBES    49I 

Througliout  the  vstroma,  in  a  section  by  Whitacre,  a  variable  amount 
of  round-celled  infiltration  with  beginning  suppuration  is  observed 
(Fig.  210),  depending  upon  the  nature  and  activity  of  the  local  infec- 
tion. In  isolated  areas,  minute  extravasations  of  blood  are  seen.  Not- 
withstanding a  local  irritation  sufficient  to  incite  these  changes,  the 
epithelial  layer  usually  remains  intact  and  does  not  even  shed  its 


Pig.  210. — "  Throughout  the  stroma,  in  a  section  by  Whitacre,  a  variable  amount  of  round- 
celled,  infiltration  with  beginning  suppuration  is  observed." — Clark. 

cilia,  although  the  cells  appear  congested  and  swollen.  From  this  stage 
on,  the  course  and  termination  of  the  inflammation  depends  upon  a 
number  of  conditions,  such  as  the  variety  of  infectious  organisms,  the 
strength  of  their  virulence,  and  the  local  resistance  of  the  tissue.  Thus, 
there  is  occasionally  observed  a  loss  of  the  epithelium  and  complete 
replacement  of  the  mucosa  by  a  cylinder  of  pus  cells  (Fig.  211). 

If  resolution  does  not  occur  in  the  acute  stage  before  detailed,  the 
inflammatory  process  tends  to  become  chronic,  when  the  extent  and 
general  characteristics  of  the  pathologic  lesions  may  become  most 
diversified. 

Morbid  Histology  of  Chronic  Salpingitis  (Salpingitis  chronica). — 
With  llie  continued  action  of  ilie  ii-ritating  agent,  be  it  the  primary 
infectious  micro-organism  or  the  toxines  generated  by  it,  the  acute 
innaiiiiiiJiiory  stage  merges  into  a  chronic  condition,  and  a  marked 


492 


A   TEXT-BOOK   OF  GYNECOLOGY 


involvement  of  the  muscular  portion  of  the  tube  occurs.  The  ser- 
pentine course  of  the  tube  becomes  more  pronounced  and  sharp  twists 
and  kinks  result.  The  tube  assumes  a  more  bluish  or  congested  appear- 
ance, and  many  vessels,  which  previously  appeared  as  capillaries,  be- 
come quite  prominent.    Through  the  sharp  kinking  of  the  tube,  micro- 


FiG.  21]   (WniTACREj. — "  Thus,  there  is  occasionally  observed  a  loss  of  the  epithelium  and 
complete  replacement  of  the  mucosa  by  a  cylinder  of  pus  cells." — Clark  (page  491). 


scopical  sections  not  infrequently  show  two  or  more  views  of  the  tubal 
lumen,  cut  transversely  or  obliquely.  As  in  all  chronic  inflammations, 
there  is  an  excessive  formation  of  new  connective  tissue,  which  renders 
the  tube  stiffer  and  much  less  flexible  than  normal. 

The  extravasations  of  blood,  which  are  microscopical  in  the  acute 
stage,  may  frequently  become  so  marked  as  to  be  visible  to  the  naked 
eye  as  bluish-red  spots.  Through  hypertrophy  and  hyperplasia  of  the 
connective  tissue  and  muscular  portions  of  the  tube,  its  wall  may  reach 
a  thickness  of  2  centimetres,  or  even  more,  in  long-standing  cases,  as 
a  result  of  the  continuous  irritation  and  destruction  of  the  tubal  epi- 
thelium; the  club-ended  villous  projections  of  the  mucosa  adhere  to- 
gether, which  not  only  decreases  the  primitive  lumen  of  the  tube,  but 
gives  it,  even  on  macroscopical  examination,  a  loculate  appearance. 
Notwithstanding  the  fact  that  this  condition  appears  most  frequently 
in  the  isthmiac  portion  of  the  tube,  a  complete  atresia  seldom  occurs. 
For  instance,  Eeymond  found  it  only  once  in  94  cases. 


INFECTIONS   AND  INFLAMMATIONS  OF   FALLOPIAN   TUBES    493 

Sooner  or  later  in  the  course  of  the  chronic  process,  plastic  lymph 
is  thrown  out  about  the  tube,  which  organizes  and  forms  adhesions  of 
varying  density  between  the  angles  of  the  distorted  tube,  and  between 
tlie  tube  and  neighbouring  viscera.  The  most  frequent  and  important 
changes  effected  by  these  adhesions  is  the  closure  of  the  fimbriated  end 
of  the  tube  (see  Hydrosalpinx  and  Pyosalpinx).  In  the  course  of  this 
atretic  process,  the  abdominal  end  of  the  tube  may  gradually  be  nar- 
rowed until  an  opening  not  larger  than  a  robin's  quill  remains.  Through 
this  gradual  narrowing,  the  secretions  may  be  more  or  less  hemmed  in, 
with  now  and  then  an  intermittent  discharge  into  the  pelvis,  giving  rise 
in  some  cases  to  an  extensive  pelvic  peritonitis. 

The  narrowing  of  the  ostium  abdominale  may  occur,  either  through 
the  gradual  adhesions  of  the  peritoneal  edges  of  the  fimbriae,  or,  as  is 
not  infrequently,  but  in  fact,  is  usually,  the  case,  the  fimbrise  become 
invaginated  within  the  tube,  and  are  then  incarcerated. 

The  small  round-celled  infiltration  which  at  times  occurs  beneath 
the  mucosa  in  the  acute  stage  becomes  generalized  in  the  chronic  pro- 
cess, until,  as  seen  in  a  section  by  Whitacre,  the  entire  tubal  wall  may 
become  involved  (Fig.  212).  From  delicate  villous  termini  the  folds 
of  the  mucosa  are  transformed  into  rounded  fusiform  ends  filling  up 
the  lumen  of  the  tube  and  lying  in  close  contact  with  each  other. 
On  account  of  this  contact  the  epithelium  becomes  destroyed,  and  the 
projections  adhere  together  and  establish  isolated  loculi  or  diverticula. 
These  spaces  may  be  gradually  obliterated  through  a  typical  granula- 
tion process,  or  the  epithelium  may  remain  intact,  and,  through  the 
accumulation  of  a  catarrhal  secretion,  be  transformed  into  larger  cystic 
cavities;  or  from  a  ciliated  cylindrical  type  the  epithelium  may  undergo 
retrograde  change  until  it  assumes  a  flattened  or  endothelial-like  ap- 
pearance. 

Through  the  projection  of  the  fusiform  villi  into  the  tubal  lumen, 
adhesions  may  take  place  between  opposing  ends  and  thus  establish 
connective  tissue  bridges  from  one  part  of  the  tube  to  another.  The 
occurrence  of  the  glandlike  space  has  further  strengthened  Hennig 
and  Bland  Sutton  in  their  belief  in  the  true  adenoid  nature  of  these 
structures.  As  stated  in  preceding  pages,  this  theory  has  found  but 
few  supporters,  for  the  adventitious  way  in  which  these  spaces  are 
formed  becomes  too  manife.st  on  critical  examination. 

In  view  of  the  fact  that  these  spaces  are  the  unmistakable  products 
of  a  pathologic  process,  Martin  prefers  the  term  salpingitis  pseudofol- 
licularis  to  salpingitis  foUicularis  as  employed  by  some  writers.  In  the 
chronic  stage  the  tubal  secretion  may  vary,  Just  as  in  the  acute  form, 
from  a  transparent  catarrhal  to  a  purulent  character. 

Upon  the  nature  of  the  secretion  depends  the  nomenclature.  The 
usual  terms  employed  in  describing  the  varieties  of  chronic  salpingitis 
are  catarrhal,  hemorrhagic,  and  purulent. 

The  hemorrhagic  salpingitis  (Salpingitis  hmmorrhagica) ,  so  far  as  its 
liistologic  clianK;t(;ristics  are  conc(!rned,  presents  no  essential  variation 


494  ^  TEXT-BOOK  OP  GYNECOLOGY 

from  the  foregoing  descrijDtion  further  than  that  induced  through  the 
deposition  of  blood  pigment  in  the  areas  of  extravasation  and  upon  the 
inner  walls  of  the  tube. 

The  tubal  secretion  is  of  a  reddish  or  chocolate-brown  colour,  due 
to  its  mixture  with  red  blood  corpuscles  in  various  stages  of  disintegra- 


FiG.  212. — "  The  small  round-celled  intiltratiou  which  at  times  occurs  beneath  the  mucosa 
in  the  acute  stage  becomes  generalized  in  the  chronic  process,  until,  as  seen  in  a  section 
by  Whitacre,  the  entire  tubal  wall  may  become  involved." — Clark  (page  493). 

tion.  Polynuclear  leucocytes  crowded  with  blood  pigment  are  seen 
in  various  parts  of  the  tissues,  and  are  especially  numerous  around  the 
ecchymotic  areas. 

In  chronic  purulent  salpingitis  the  tubal  secretion  consists  largely 
of  pus,  varying  in  appearance  from  a  flocculent  sero-purulent  character 
to  a  thick  yellowish  or  greenish  colour.  If,  as  a  result  of  a  severe 
infection,  purulent  salpingitis  sets  in  at  the  very  beginning  without 
an  appreciable  catarrhal  change,  the  local  inflammatory  changes  be- 


INFECTIONS  AND   INFLAMMATIONS   OF   FALLOPIAN   TUBES    495 

come  most  pronounced,  consisting  in  an  excessive  transmigration  of 
leucocytes,  a  rapid  round-celled  infiltration,  and  a  rapidly  increasing 
oedema  of  the  mucosa.  Through  these  hypertrophic  changes,  the  tube 
assumes  a  size  much  greater  than  the  normal.  Martin  has  attempted 
to  establish  a  differentiation  through  microscopic  examination  between 
the  acute  septic  salpingitis  and  the  acute  gonorrhoeal  salpingitis. 

According  to  our  view,  unless  the  infectious  micro-organism  is  rec- 
ognised either  through  cultures  or  through  cover-glass  preparations, 
we  do  not  believe  this  differentiation  through  a  simple  histological 
examination  is  possible  except  in  the  hands  of  an  expert  microscopist, 
and  even  then  the  results  must  be  viewed  with  considerable  scepticism. 

Through  the  closure  of  the  ostium  abdominale,  the  tube  becomes 
more  or  less  distended,  and,  according  to  the  nature  of  its  secretion,  is 
called  a  hydrosalpinx,  hematosalpinx,  or  pyosalpinx. 

Hydrosalpinx  {Hydrops  tubarum,  Sadosalpinx)  is  a  pathologic  col- 
lection of  serous  fluid  within  the  Fallopian  tube  due  to  a  partial  or 
complete  stricture  in  some  part  of  the  tube. 

While  a  pathologic  atresia  may  occur  at  any  point  in  the  tube,  the 
usual  seat  is  at  the  fimbriated  end.  In  rare  cases,  more  than  one 
stricture  may  take  place,  which  divides  a  simple  hydrosalpinx  into  two 
or  more  chambers. 

According  to  Eokitansky,  the  occlusion  of  the  fimbriated  end  is  due 
to  the  adhesion  of  the  peritoneal  surfaces  of  the  fimbriae,  which  become 
inverted  within  the  tube.  Klob  ofi^ers  a  similar  explanation  and  attrib- 
utes the  adhesions  to  a  tubal  catarrh,  perisalpingitis,  or  pelviperitonitis. 

According  to  Klebs,  atrophy  of  the  fimbrias  may  result  from  a  local- 
ized inflammation  leading  to  an  inversion  of  the  flmbrige  and  a  filling 
in  of  the  ostium  abdominale  with  scar  tissue.  While  these  strictures 
of  the  tube  may  result,  in  rare  instances,  from  other  than  inflammatory 
causes,  as,  for  instance,  the  dropsical  accumulation  in  the  tube  in  cer- 
tain cases  of  myoma,  nevertheless,  the  chief  inciting  factor  is  un- 
doubtedly a  perisalpingitis.  Whether  the  inflammatory  condition  is 
always  of  bacterial  origin,  is  as  yet  an  open  question.  Menge  and 
others  have,  for  instance,  described  numerous  cases  in  which  the  occlu- 
sion occurred  through  a  sterile  process,  such  as  the  chemical  irritation 
of  hemorrhagic  accumulations,  and  from  the  mechanical  congestion 
due  to  the  pressure  of  tumours,  etc.  These  cases,  however,  are  com- 
paratively rare,  and,  as  a  rule,  the  first  cause  may  be  accepted  as  the 
chief  one. 

While  it  is  generally  conceded  that  hydrosalpinx  is  sui  generis  a 
dropsical  accumulation,  yet  such  eminent  authorities  as  Zweifel  and 
Bland  Sutton  believe  that  it  may  result  from  the  resolution  of  a  pyo- 
salpinx, the  purulent  matter  undergoing  a  transformation  into  an 
aqueous  accumulation. 

Menge,  Kleinliaus,  and  others,  as  the  result  of  careful  observation, 
state  with  positive  assurance  that  such  a  retrograde  metamorphosis 
is  not  possible,  for  they  say  tliat,  although  pus  may  become  thick  and 


496  A  TEXT-BOOK   OF  GYNECOLOGY 

inspissated,  it  never  undergoes  liquefaction,  and  also  that  the  his- 
tological changes  in  hydrosalpinx  are  radically  different  from  those 
observed  in  pyosalpinx.  Upon  the  basis  of  Clark's  observations  an 
unqualified  support  to  the  latter  opinion  may  be  given. 

As  a  general  rule,  hydrosalpinx  is  attributable  to  puerperal  rather 
than  to  gonorrhceal  infection.  Menge,  for  instance,  holds  very  strongly 
to  the  belief  that  the  gonococcus  is  a  pus-producer,  that,  consequently, 
a  purulent  salpingitis  or  pyosalpinx  is  usually  produced  by  it,  and  that 
only  in  rare  instances  does  hydrosalpinx  result  from  this  micro-organ- 
ism, and  then  only  as  a  secondary  process.  In  explaining  the  latter 
statement,  he  says  that  the  primary  gonorrhceal  salpingitis  may  have 
reached  its  climax  and  be  undergoing  resolution  when,  as  a  result  of  a 
secondary  pelvic  peritonitis,  the  ostium  abdominale  may  become  oc- 
cluded with  a  simple  hydrosalpinx  as  a  sequel. 

Von  Eosthorn  maintains  with  forcible  argument  that  hydrosalpinx 
is  always  induced  by  a  pelvic  peritonitis.  He  says  that  streptococci  or 
staphylococci  gain  entrance  to  the  tube,  and,  because  of  attenuated 
virulence,  only  a  simple  catarrhal  salpingitis  is  inaugurated,  and  that 
later,  through  continuity  of  structure,  the  pelvic  peritoneum  becomes 
involved  and  the  tube  is  thus  sealed  by  adhesions.  Coincidently  with 
this  occlusion,  the  secretion  of  the  tube  begins  to  accumulate,  first 
distending  the  abdominal  end,  then  progressively  extending  toward 
the  isthmiac,  or  uterine,  extremity  of  the  tube.  Quite  naturally  the  dis- 
tortion decreases  toward  the  uterus  on  account  of  the  greater  resistance 
offered  b}^  the  tube. 

The  escape  of  fluid  is  prevented  or  greatly  retarded  through  ad- 
hesions, organic  occlusion,  mechanical  torsion,  or  kinks  at  the  uterine 
juncture  of  the  tube.  As  stated  under  the  head  of  Salpingitis,  an 
actual  closure  of  the  lumen  of  the  isthmiac  portion  of  the  tube  through 
inflammatory  changes  is  comparatively  rare.  With  the  increase  in  the 
accumulation  of  fluid  within  the  tube,  its  wall  undergoes  a  gradual 
thinning,  and,  although  a  marked  pressure  atrophy  may  ultimately  take 
place,  the  visible  landmarks  of  the  longitudinal  folds  of  the  mucosa 
will  appear  as  ridges  running  direct  from  the  vestibular  to  the  isthmiac 
extremity  of  the  tube. 

Upon  the  degree  of  distention  depends  the  variation  in  the  mor- 
phology, the  size  ranging  from  that  of  a  lead  pencil,  with  more  or  less 
conformation  to  the  normal  undulations  of  the  tube,  to  a  very  large  fusi- 
form tumour  with  a  smooth  glistening  exterior.  As  the  tube  is  gradu- 
ally transformed  from  its  normal  shape  it  may  assume  a  sausagelike, 
serpentine,  or  what  is  more  usual,  a  retort  or  pipe  shape.  In  rare 
instances,  the  tube  may  reach  very  large  dimensions,  and  the  morpho- 
logic characteristics  may  be  so  obscured  as  to  render  its  identification 
very  difficult  on  account  of  the  close  resemblance  to  a  tubo-ovarian, 
ovarian,  or  parovarian  cyst.  Even  in  cases  of  moderate  distention, 
the  muscular  and  connective-tissue  layers  may  become  so  attenuated  as 
to  allow  the  contents  of  the  tube  to  be  seen  through  its  transparent  wall. 


INFECTIONS  AND   INFLAMMATIONS  OF   FALLOPIAN  TUBES    497 

The  tubal  secretion  may  be  of  a  clear  limpid,  a  yellowish  lemon,  or  a 
slightly  blood-tinged  colour,  and  its  formed  elements  may  consist  of 
leucocytes,  epithelium,  red  blood  cells,  and  sometimes  cholesterine 
crystals.  To  the  latter.  Bland  Sutton  ascribes  the  greenish  colour 
occasionally  noted  in  the  fluid. 

With  the  progressive  increase  in  the  size  of  the  tube,  the  mucosa 
loses  its  coral-like  or  villous  appearance,  becomes  greatly  stretched,  and 
may  undergo  such  complete  atrophy  as  to  leave  only  the  small  ridges 
before  described,  or,  as  is  seen  in  some  cases  only,  small  blunt  teatlike 
eminences. 

Of  the  mucosa  the  epithelium  alone  remains,  and  this  is  usually 
transformed  into  a  cuboidal  or  flattened  variety;  in  the  deep  angles  and 
protected  areas  it  may,  however,  still  maintain  its  cylindrical  character, 
and  even  the  cilia  may  remain  intact. 

As  a  unique  and  rare  production,  bonelike  or  calcareous  plates  are 
found  in  the  walls  of  the  tubes,  or,  as  illustrated  by  Cullen's  case,  the 
tube  may  contain  a  calculus. 

Hydrosalpinx  does  not,  as  a  rule,  reach  a  large  size,  although  cases 
are  reported  in  which  the  contents  measured  a  litre  or  more. 

With  regard  to  the  comparative  frequency  of  single  or  double 
hydrosal]3inx,  it  is  usually  stated  that  the  double  form  is  the  more 
conunon.  To  the  contrary,  however,  Cullen  states  that  in  a  series  of 
27  cases,  he  found  17  unilateral  while  the  remainder  were  bilateral. 

Types  of  Hydrosalpinx. — Certain  deviations  in  morphology  from 
the  simple  form  just  described  constitute  special  types  of  hydrosalpinx. 
Occlusion  of  the  tube  in  salpingitis  pseudofollicularis,  with  its  sub- 
sequent enlargement,  constitutes  hydrosalpinx  pseudofollicularis.  In 
this  condition  the  tube  rarely  reaches  such  a  large  size  as  the  simple 
form,  from  purely  mechanical  reasons,  for  it  is  self-evident  that  a 
cavity  divided  into  numerous  loculi  can  not  distend,  on  account  of 
increased  resistance,  .with  the  same  facility  as  a  unilocular  cavity. 

Cross  sections  of  the  tube  present  a  spongelike  or  irregular 
punched-out  appearance,  the  larger  cavities  being  lined  with  cuboidal, 
the  smaller  with  simple  cylindrical  or  ciliated  epithelium.  In  some 
vSpaces,  desquamated  ejDithelia  are  seen. 

As  a  special  variety,  named,  not  because  of  its  histological  deviation 
from  the  simple  variety,  but  on  account  of  its  intermittent  discharge 
of  fluid  into  the  uterus,  is  the  hydrops  tubce  profluens.  In  these  cases 
the  tube  may  reach  a  very  large  size  before  the  sphincterlike  action  at 
the  uterine  cornu  is  overcome,  when  a  profuse  serous  flux  is  noticed 
by  the  patient.  This  is  a  comparatively  rare  condition,  only  isolated 
instances  having  been  reported  from  even  the  largest  clinics. 

This  peculiar  intermittent  action  of  the  tube  is  attributed  to  sev- 
eral causes.  According  to  Landau,  the  muscular  walls  at  the  uterine 
juncture  are  greatly  hypertrophied,  and  only  when  this  constriction  is 
overcome  by  the  vis  a  tergo  of  the  serous  accumulation  is  the  periodical 
flow  inaugurated. 
33 


498 


A  TEXT-BOOK  OP   GYNECOLOGY 


Other  investigators  have  attributed  this  condition  to  a  stricture  of 
the  tube  which,  like  the  kinked  garden  hose,  is  only  overcome  by 
the  gradual  increase  in  pressure  behind  the  point  of  constriction. 

The  last  variety  of  hydrosalpinx,  known  as  tubo-ovarian  cyst  (Fig. 
313),  is  a  pathologic  condition  in  which  the  hydrops  tubte  is  associated,, 
by  organic  union,  with  a  cystic  condition  of  the  ovary,  the  fluid  from 
one  cavity  mingling  with  that  of  the  other. 

These  aqueous  tumours  vary  from  a  very  small  to  a  very  large  size, 
reaching  in  some  instances  a  diameter  equivalent  to  that  of  a  child's 
head.  With  a  free  conununication  between  two  secreting  cavities,  such 
as  one  finds  in  these  cases,  it  is  quite  natural  for  the  cystic  tumour  to 
reach  much  larger  dimensions  than  the  simple  hydrosalpinx. 

The  Fallopian  tube  is  situated  upon  the  upper  surface  of  the  tumour 
and  usually  appears  as  a  large  club-shaped  or  retort-shaped  body,  which 


Fig.  213. — "The  variety  of  hydrosalpinx  known  as  tubo-ovarian  cyst." — Clark. 


is  fused  at  its  fimbriated  extremity  onto  the  surface  of  the  ovary  by 
adhesions  of  more  or  less  density,  depending  upon  the  chronicity  of  the 
inflammatory  process. 

The  communication  between  the  cystic  portion  of  the  ovary  and 
the  tube  may  be  established,  either  by  the  primary  adhesion  of  the 
spread-out  fimbriae  upon  the  surface  of  the  cyst  with  a  subsequent  rup- 
ture into  the  tube,  or  the  free  fimbriae  may  become  incarcerated  within 
the  ruptured  opening  of  a  cystic  Graafian  follicle  or  other  ovarian  cyst. 
In  general  appearance,  the  tubal  portion  of  this  combined  tumour  does 
not  difi^er  from  the  usual  hydrosalpinx,  while  the  ovarian  portion  con- 
forms to  the  usual  classification  of  the  simple  unilocular,  multilocular, 
or  glandular  cysts. 

Where  the  adhesions  are  quite  dense  and  the  tube  and  ovary  are 
fused  together  in  a  very  close  organic  mass,  it  may  be  difficult  or 


INFECTIONS  AND  INFLAMMATIONS  OF   FALLOPIAN  TUBES    499 

impossible  to  recognise  macroscopically  the  loeuli  which  originate  in 
the  ovary  from  those  of  the  tube.  In  such  instances,  however,  a  dis- 
tinction may  be  made  microscopically,  through  the  recognition  of  the 
characteristic  ovarian  stroma  and  constituent  cells  of  the  Graafian  fol- 
licle. 

Hematosalpinx  (Sadosalpinx  hcemorrhagica)  is  a  collection  of  blood 
within  an  occluded  tube,  similar  to  the  serous  collection  in  a  hydro- 
salpinx. Until  quite  recently  all  hemorrhagic  tubal  collections  have 
been  placed  under  this  classification.  Veit,  however,  has  shown  that 
this  is  an  error,  as  the  hemorrhage  incident  to  a  tubal  pregnancy  or 
to  a  malignant  growth  is  merely  an  accidental  product,  and  should, 
therefore,  not  be  given  this  misleading  name. 

Hematosalpinx  is  produced  through  sharp  kinks  and  torsion  of  the 
tube,  thrombosis  of  the  tubal  vessels,  and  from  simple  hemorrhage  into 
a  hydrosalpinx. 

Less  common  causes  are  acquired  or  congenital  atresia  of  the  uterus 
or  vagina,  traumatisms  of  the  inner  genitalia,  and  the  injuries  of 
severe  labours.  Although  the  majority  of  cases  may  be  attributed  to 
some  one  of  these  easily  recognised  causes,  there  is  still  a  considerable 
number  of  cases  in  which  the  minutest  history  and  most  painstaking 
physical  and  microscopic  examinations  have  failed  to  reveal  the  true 
etiology.  Martin  ascribes  some  cases  to  vicarious  menstruation,  while 
others  attribute  this  condition  to  a  reflux  of  menstrual  blood  from  sud- 
den spastic  uterine  contractions.  Sanger  asserts  that  an  aseptic  accu- 
mulation of  blood  in  the  pelvis  may  induce  a  localized  peritonitis, 
through  which  the  abdominal  ostium  becomes  occluded  while  the  tubal 
hemorrhage  is  still  in  action.  The  pathologic  changes  observed  in 
these  cases  depend  upon  the  primary  cause  of  the  hematosalpinx. 
When  the  intratubal  hemorrhage  is  induced  through  a  strangulation 
of  the  tube,  the  vessels  are  thrombosed  and  numerous  areas  of  extrava- 
sation within  the  tubal  wall  are  found,  and  in  some  instances  large  in- 
farctions may  occur. 

The  tissues  always  stain  badly  and  microscopical  sections  frequently 
show  very  much  obscured  histologic  characteristics.  More  or  less  ex- 
tensive hemorrhagic  necroses  frequently  take  place,  but  are  sharply 
limited  by  the  line  of  strangulation. 

In  the  simple  cases  where  the  blood  is  either  shed  from  the  mucosa 
into  a  hydrosalpinx,  or  where  it  reaches  the  tube  as  a  reflux  from  the 
uterus,  the  histologic  picture  presents  no  essential  structural  devia- 
tions from  those  observed  in  hydrosalpinx.  The  inner  wall  of  the 
tube  is  covered  with  a  pigmentary  deposit  and  the  mucosa  may  be  the 
seat  of  minute  capillary  extravasations.  Leucocytes  laden  with  blood 
pigment  are  also  found  within  the  vessels  and  as  wandering  cells  in  the 
tissues. 

Pyosalpinx  (Sadosalpinx  purulenta;  suppuration  of  the  tube)  is  a 
purulent  collection  within  the  Fallopian  tube,  which  arises  as  a  result 
of  offliisioii  in  some  part,  usually  at  the  ostium  abdominale,  of  an  in- 


500  A   TEXT-BOOK  OF   GYNECOLOGY 

flamed  tube.  Quite  naturally,  an  agent  sufficient  to  induce  this  secre- 
tion of  pus  is  of  a  more  irritant  nature  than  that  found  in  a  simple 
catarrhal  process,  consequently  the  inflammatory  reaction  is  usually 
much  more  marked.  The  extent  of  the  involvement  is  variable,  and 
the  size  of  the  tube  and  the  thickness  of  its  walls  depend  upon  the 
degree  of  distention.  When  the  quantity  of  pus  is  small,  the  tubal  walls 
are  usually  greatly  swollen  and  the  thickness  may  exceed  the  normal 
many  fold,  whereas  in  a  large  tense  pyosalpinx  the  opposite  condi- 
tion may  be  noted,  just  as  in  a  hydrosalpinx.  So  far  as  size  is  con- 
cerned, a  23yosali)inx  as  a  rule  does  not  reach  that  of  a  hydrosalpinx, 
although  instances  are  recorded  in  which  an  enormous  abscess  has 
developed. 

Upon  the  intensity  and  chronicity  of  the  inflammatory  process  also 
depends  the  appearance  and  character  of  the  pyosalpinx,  for  with  the 
long  jDersistence  of  the  infection  there  is  a  steady  increase  in  the 
amount  of  connective  tissue,  which  transforms  the  tube  from  a  flexible 
to  a  stiff  resistant  condition.  JSTotAvithstanding  the  presence  of  a  very 
irritating  infectious  matter  the  lining  epithelium  may  remain  intact  a 
surprisingly  long  time;  but  sooner  or  later  it  is  completely  destroyed 
in  those  areas  exjjosed  to  the  contact  of  the  pus,  and  is  supplanted  by 
granulation  tissue. 

As  a  result  of  the  direct  extension  of  the  inflammation  through  the 
wall  of  the  tube  or  from  local  infection  of  the  enveloping  peritoneum 
by  escape  of  the  pus  from  the  ostium  abdominale,  the  tube  is  usually 
covered  with  adhesions  which  bind  it  to  the  neighbouring  organs.  The 
organization  of  the  adhesions  often  binds  the  ovary  into  an  indistin- 
guishable mass  with  the  tube,  and  in  such  cases  abscesses  often  form 
in  the  sjjaces  between  these  organs,  or  between  the  intestines  and 
tube  (perisalpingeal  abscess),  thus  converting  the  mass  into  multiple 
suppurating  loculi. 

Just  as  the  tubo-ovarian  cyst,  described  in  preceding  pages,  is 
formed,  so  may  these  cases  be  converted  into  tubo-ovarian  abscesses. 
The  ovary,  however,  notwithstanding  its  close  proximity  to  the  tube, 
is  very  often  free  from  infection,  there  being  only  a  simple  peri- 
oophoritis which  does  not  penetrate  beyond  the  tunica  albuginea. 

The  contents  of  a  pyosalpinx  vary  in  consistence  from  a  thin  yel- 
lowish purulent  fluid  to  a  thick  inspissated  cheesy  matter,  consisting 
of  disorganized  pus  corpuscles  and  red  blood  cells,  flbrin,  degenerated 
epithelium,  and  granular  detritus. 

As  a  rule  the  culture  and  microscopic  evidence  of  micro-organisms 
give  negative  results. 

In  the  earlier  stages  of  the  pyosalpinx,  granulation  tissues  may  take 
the  place  of  the  mucosa  and  the  underlying  tissue  become  richly 
infiltrated  with  round  cells;  later,  however,  the  granulations  are  trans- 
formed into  dense  scar  tissue  and  ordinary  connective  tissue.  As  the 
inflammatory  process  becomes  chronic,  the  muscular  tissue  undergoes 
marked  atrophy  until  mere  traces  only  may  remain.     The  vessels  be- 


INFECTIONS  AND   INFLAMMATIONS  OF   FALLOPIAN  TUBES    501 

neath  the  peritoneum  become  thick  and  tortuous,  and  sooner  or  later 
show  hyaline  degeneration.  In  some  cases  the  tubal  wall  may  become 
quite  oedematous.  Even  in  simple  cases,  isolated  spaces,  like  those  in 
salpingitis  pseudofollicularis,  are  seen,  which  are  lined  by  granulation 
or  scar  tissue  and  contain  pus.  When  a  typical  case  of  salpingitis 
pseudofollicularis  is  converted  into  a  pyosalpinx,  cross  sections  of  the 
tube  show  an  exaggerated  loculated  appearance.  As  a  result  of  simple 
inflammation  or  from  the  deposition  of  lymph  which  undergoes  organi- 
zation, the  peritoneum  may  become  very  greatly  thickened. 

Symptoms  and  Diagnosis  of  Salpingitis. — Although  we  may  have 
a  morbid  process  strictly  confined  to  the  tube — a  salpingitis — we  much 
more  frequently  find  that  other  tissues  have  been  implicated  at  the 
same  time.  -More  especially  is  this  true  of  the  pelvic  peritoneum;  and 
in  many  cases,  therefore,  the  symptoms  of  a  salpingitis  are  largely  modi- 
fied by  the  virulence  and  extent  of  the  accompanying  peritonitis. 

General  Considerations. — The  symptoms  of  inflammation  of  the 
uterine  appendages  and  the  pelvic  peritoneum  vary  with  the  extent  and 
character  of  the  infection.  The  less  virulent  the  infecting  agent, 
and  the  greater  the  resisting  power  of  the  various  anatomic  structures 
it  encounters,  the  more  limited  is  the  extent  of  the  morbid  process 
and  the  less  severe  its  general  and  local  effects  upon  the  organism. 

In  primary  tubal  infections,  Nature  often  prevents  the  direct  exten- 
sion to  the  other  pelvic  tissues  by  sealing  the  fimbriated  end  of  the 
tube.  It  is  true  that  the  morbid  process  sometimes,  though  very 
seldom,  makes  its  way  through  the  walls  of  the  tube,  but  in  such 
cases  the  battle  is  prolonged,  and  the  resistance  being  greater,  the  other 
tissues  of  the  pelvic  cavity  are  only  implicated  to  a  limited  extent. 
When  the  inflammation  has  been  only  just  severe  enough  to  seal  up 
the  fimbriated  extremity  of  the  tube,  the  mucous  membrane  may  be 
left  in  a  practically  unaltered  condition,  but  the  normal  secretion 
being  poured  out  dilates  the  cavity.  If  this  condition  is  speedily  re-, 
lieved  by  the  escape  of  the  exudate  into  the  pelvic  cavity  or  into  the 
uterus,  the  symptoms,  so  far  as  the  tube  itself  is  concerned,  may  be 
imperceptible.  But  since  the  tube  is  much  less  sensitive  to  pain  than 
the  uterus  and  ovaries,  even  when  the  exudate  is  localized  and  retained 
in  it,  but  little  disturbance  may  be  caused.  For  this  reason  the  milder 
catarrhal  inflammations,  even  when  acute,  may  cause  symptoms  too 
slight  to  fix  the  patient's  attention  definitely  upon  the  diseased  part. 
They  may,  indeed,  run  their  course  and  disappear  without  ever  having 
been  recegnised,  leaving  behind  hardly  any  perceptible  trace.  So  fre- 
quently do  these  processes  escape  notice,  that  it  may  be  said  that  in 
an  acute  or  chronic  catarrhal  salpingitis  the  symptoms  are  seldom  of 
a  prominence  sufficient  to  give  rise  to  the  suspicion  that  any  disease  is 
present. 

In  th(;  cases  which  present  symptoms  there  is  more  or  less  localized 
[tfiin  or  fliscomfort,  the  nature  and  intensity  of  which  varies  within 
vvidf  liiiiiis.     ''I'll IIS,  sonictinies  the  patient  complains  rather  of  a  dull 


502  A  TEXT-BOOK   OF   GYNECOLOGY 

aching  or  burning  sensation,  which  only  becomes  a  real  pain  when  she 
mores  about  or  goes  up  or  down  steps,  or  when  local  pressure  upon 
the  parts  is  exerted  by  walking,  defecation,  or  the  various  manipula- 
tions of  the  examining  physician.  And  yet,  desi^ite  this,  the  tube  may 
be  distended  and  almost  ready  to  burst  (Fig.  230). 

In  the  so-called  colica  scortorum  the  attack  is  characterized  from 
the  beginning  by  sharp  colick}^  pains  in  the  region  of  the  tubes.  These 
come  on  in  paroxysms,  while  in  the  intervals  the  patient  enjoys  com- 
parative comfort.  This  intercurrent  pain  is  considered  by  Schauta  to 
be  characteristic  of  salpingitis  isthmiaca  nodosa.  In  other  cases,  as  has 
been  said,  the  intense  pain  points  rather  to  extension  of  the  process 
to  the  peritoneum  or  the  ovaries. 

To  a  large  extent  the  sufferings  of  the  patient  are  due  to  mechanical 
causes.  It  can  be  readily  seen  that  greatly  dilated  and  swollen  tubes, 
especially  when  the  filling  up  has  been  rapid  and  the  tissues  have  not 
had  time  to  adapt  themselves  to  the  stretching,  might  give  rise  to 
intense  pain,  particularly  if  the  pelvic  tissues  around  are  inflamed  and 
sore.  Hence  the  mechanical  symptoms  may  be  numerous.  The  pres- 
sure or  dragging  upon  the  different  tissues  may  give  rise  to  painful 
defecation  and  micturition,  difficulty  and  pain  on  standing  or  moving 
about,  together  with  pressure  neuralgias  and  symptoms  referred  to  the 
digestive  tract  or  the  cerebro-spinal  system,  all  of  which  may  be 
reflex  in  origin.  At  the  time  of  menstruation,  the  congestion  of  the 
ovar\%  which  is  often  bound  do^\Ti  together  with  the  tube  by  firm  adhe- 
sions, resisting  its  expansion,  doubtless  accounts  for  not  a  little  of 
the  pain.  The  great  possible  variety  and  intensity  of  these  mechanical 
disturbances  should  always  be  kept  in  mind.  Though,  as  a  rule,  it 
ma}"  be  said  that  marked  aggravation  of  the  symptoms  with  nausea, 
fever,  abdominal  distention,  tenderness,  drawing  up  the  thighs,  and 
a  pinched  expression  of  the  face,  point  to  the  development  of  a  general 
peritonitis,  we  may  sometimes  at  operation  be  agreeably  surprised  to  find 
that  the  inflammation  is  localized  to  one  or  more  parts  of  the  peri- 
toneum, and  that  the  mechanical  factors  of  pressure  or  traction  have 
been  sufficient  to  give  rise  to  indications  of  the  existence  of  the  more 
alarming  condition. 

During  the  monthly  period  the  pathologic  congestion  is  increased, 
so  that  dysmenorrhoea  is  common.  In  most  cases  of  tubal  disease 
there  is  usually  an  increase,  rather  than  a  decrease,  in  the  menstrual 
flow,  and  even  menorrhagia  may  be  present.  Absent  or  scanty  men- 
struation should  make  us  suspect  tuberculosis.  Sterility  is  a  common 
symptom  in  tubal  disease,  and  is  due,  either  to  mechanical  obstruction 
to  the  passage  of  the  ovum  or  spermatozoa,  or  to  the  distinctive  influ- 
ence exercised  upon  them  by  the  poisonous  material  which  they  en- 
counter in  the  tube. 

In  a  large  number,  one  might  say  in  the  majority,  of  cases  of  pelvic 
disease,  a  satisfactory  diagnosis  can  only  be  arrived  at  after  an  examina- 
tion under  anaesthesia.     The  relaxation  of  the  abdominal  muscles  en- 


INFECTIONS  AND   INFLAMMATIONS  OF   FALLOPIAN  TUBES    503 

ables  us  to  examine  more  thoroughly^  and  at  the  same  time  does  away 
with  the  necessity  of  using  any  violence.  Hence  the  safety  of  the 
patient  is  secured,  as  well  as  the  means  of  making  a  more  satisfactory 
diagnosis.  A  thorough  evacuation  of  the  bowels  and  of  the  bladder 
should  always  be  provided  for.  Combined  internal  and  external  palpa- 
tion is  necessarv'.  The  right  hand  being  placed  over  the  h}7>oga.strium 
assists  the  left  index  finger  in  the  vagina;  or  the  index  finger  may  be 
inserted  into  the  rectum  and  the  thumb  into  the  vagina.  In  cases  of 
adnexal  disease  it  will  generally  be  possible  to  make  out  on  one  or  both 
sides  a  mass,  which  in  most  cases  proves  to  be  the  inflamed  tube,  or 
this  together  with  other  structtires  implicated,  according  to  the  char- 
acter or  extent  of  the  process.  To  decide  as  to  the  nature  and  limits 
of  the  various  component  parts  of  the  mass  is  often  difficult  or  even 
impossible.  Again,  there  are  quite  a  number  of  conditions  which  may 
be  confused  with  adnexal  inflammation,  the  principal  of  these  being: 

1.  Tumours  of  the  uterus,  tubes,  broad  ligaments,  intestines, 
sacrum,  and  ilium. 

2.  Appendicitis. 

3.  Intestinal  adhesions. 

4.  Faecal  accumulations. 

5.  Extra-uterine  pregnancies. 

6.  Uterine  displacements. 

7.  Parametritis. 

8.  In  rare  cases  a  displaced  kidney,  spleen,  or  other  abdominal 
visctis.  may  simulate  a  pathologic  condition  of  the  adnexa. 

A  myoma  developing  lateralward  from  the  uterus  may  simulate 
in  form  and  location  a  sactosalpinx.  As  a  rule,  however,  the  former, 
being  more  closely  incorporated  with  the  uterus,  causes  an  enlarge- 
ment of  the  body.  ^Myomata  develop  gradually,  are  frequently  pain- 
less, and  are  characterized  by  more  profuse  menorrhagia  than  is  com- 
mon itt  tubal  disease.  Again,  while  the  symptoms  due  to  pressure  are 
more  marked,  those  indicative  of  inflammation  are  absent  in  uncom- 
plicated myomata. 

In  neoplasms  of  the  tubes  and  broad  ligaments,  we  have  an  absence 
of  a  history  and  of  symptoms  of  infection.  Again,  new  growths  are 
less  painful,  of  slower  development  than  the  masses  resulting  from 
adnexal  inflammations,  and  at  the  same  time  they  are  not  so  likely  to 
produce  adhesions  so  early.  Only  when  such  do  not  exist,  will  the 
recognition  of  the  masses  as  distinct  from  the  adnexa  be  possible  and 
render  the  diagnosis  certain. 

Ovarian  tumours  are  often  distinguished  from  instances  of  sacto- 
salpinx  only  by  means  of  an  exploratory  incision.  The  following  points 
of  distinction,  however,  should  always  be  remembered:  A  tumour  of 
the  ovary  is  more  likely  to  assume  a  somewhat  globular  shape,  while  a 
sactosalpinx  is  rather  elongated.  Again,  the  saetosalpinx;  can  often  be 
made  out  to  be  nearer  the  uterus,  and  if  the  ovary  can  be  isolated  in 
addition  to  a  tumour  between  it  and  the  corpus,  the  diagnosis  is  ren- 


504  A  TEXT-BOOK  OF   GYNECOLOGY 

dered  comparatively  easy.  Large  ovarian  tumours  can  be  distinguished 
by  their  size,  but  in  the  case  of  small  parovarian  or  ovarian  cysts  and 
solid  tumours,  when  the  course  of  the  tube  can  not  be  followed  from 
the  uterus  to  the  ovary,  a  diagnosis  is  usually  impossible.  Sometimes 
a  distended  tube  may  be  felt  above  the  brim  of  the  pelvis  and  may 
simulate  very  closely  a  suppurating  ovarian  c3'Stoma.  Here,  the  history 
and  examination  give  us  no  help  toward  a  diagnosis. 

Appendicitis. — When  there  exists  no  tubal  disease,  the  history  and 
symptoms  coupled  with  the  physical  examination  will  aid  us  in  making 
our  diagnosis.  Again,  the  pain  of  an  appendicitis  is  more  often  local- 
ized, or  at  any  rate  has  a  maximum  intensity,  over  McBurney's  point, 
while  that  of  adnexal  disease  is  most  prominent  lower  down,  in  what 
is  known  as  the  ovarian  region. 

When,  however,  an  appendicitis,  as  happens  not  infrequently,  com- 
plicates a  salpingitis,  a  diagnosis  of  the  former  condition  is  generally 
made  only  at  operation. 

Intestinal  adhesions  and  intestinal  obstruction  from  pelvic  inflamma- 
tion, except  when  a  loop  of  intestine  is  adherent  to  the  tubes  or  broad 
ligaments,  can  generally  be  made  out  by  physical  examination,  espe- 
cially when  the  tubes  are  not  imjDlicated.  In  intestinal  obstruction, 
the  onset  is  generally  more  sudden,  and  the  symjjtoms  on  the  part  of 
the  bowels  are  suggestive. 

Fcecal  accumulations  in  the  rectum  can  be  made  out  with  the  ex- 
amining finger. 

Extra-uterine  pregnancy  has  usually  begun  in  the  tube,  and  we  may 
therefore  feel  what  appears  to  be  an  inflammatory  sactosalpinx.  Here, 
however,  we  have  a  history  and  certain  symptoms  pointing  to  preg- 
nancy. Enlargement  of  both  tubes  excludes  an  ectopic  pregnancy 
except  in  those  very  rare  instances  in  which  we  have  a  sactosalpinx  on 
one  side  and  a  tubal  pregnancy  on  the  other. 

Uterine  displacements  may  frequently  lead  to  confusion.  A  dis- 
placed corpus  uteri  may  often  simulate  an  inflammatory  mass,  but  the 
recognition  by  means  of  conjoined  palpation  and,  when  necessary,  the 
use  of  the  sound,  will  seldom  fail  to  guide  us  to  a  correct  diagnosis. 

The  diagnosis  of  parametritis  and  its  relation  to  adnexal  disease 
have  been  discussed  in  another  place. 

Hematoma. — Here  the  history  will  aid  us.  With  a  large  flow  of 
blood  into  the  pelvic  cavity  from  rupture  of  a  tubal  gestation  or  other 
cause,  we  have  generally  acute  pain,  without  signs  of  inflammation, 
but  with  those  of  more  or  less  severe  internal  hemorrhage.  Only 
when  the  hematoma  has  become  infected,  will  signs  of  pelvic  abscess 
appear. 

Finally,  it  may  be  said  that,  even  after  we  have  arrived  at  a  diag- 
nosis of  adnexal  disease,  it  will  often  be  impossible  to  decide  absolutely 
whether  the  tube  or  ovary  or  both  are  implicated.  Nor  shall  we 
always  be  able  to  say  before  operation,  in  the  case  of  tubal  disease,  the 
exact  condition  which  exists,  or  to  arrive  at  the  etiological  factor. 


INFECTIONS  AND   INFLAMMATIONS   OF  FALLOPIAN  TUBES    505 

until  a  bacteriological  examination  has  decided  the  matter.  Suggestive 
information  can  often  be  obtained  from  examination  of  the  vaginal  dis- 
charge. 

Having  referred  to  the  symptoms  and  diagnosis  of  disease  of  the 
adnexa  in  general,  it  will  be  well  to  take  up  the  different  forms  of  sal- 
pingitis separately  and  give  somewhat  more  in  detail  their  distinctive 
characteristics. 

Hydrosalpinx. — When  the  inflammation  has  been  only  sufficient  to 
glue  the  fimbrige  together,  it  is  quite  possible  for  the  tube  to  be  dis- 
tended with  a  serous  exudate  (the  natural  secretion  which  is  now  pent 
up)  without  giving  rise  to  any  symptoms,  unless  indeed  the  resulting 
tumour  should  be  of  a  size  sufficient  to  cause  mechanical  disturbances. 
But  the  distended  portion  of  the  tube  hardly  ever  exceeds  the  size 
of  an  average  orange,  and  the  neighbouring  parts  easily  accommodate 
themselves  to  their  slight  change  in  position,  especially  if  it  comes 
about  gradually.  When  the  process  has  invaded  the  serous  membrane 
with  more  virulence,  we  have,  as  might  be  expected,  a  degree  of  pain 
corresponding  to  the  grade  of  inflammation  and  the  number  and  ex- 
tent of  the  adhesions. 

Leucorrhceal  discharges  are  common  in  the  majority  of  pathologic 
conditions  affecting  the  uterus  or  the  adnexa.  In  a  pure  catarrhal  con- 
dition confined  to  the  tube,  the  discharge  is  generally  of  a  whitish  char- 
acter. A  muco-purulent  discharge  points  rather  to  inflammation  of  the 
endometrial  lining  of  the  uterine  cavity,  and  is  not  caused  by  a  localized 
peritonitis.  The  jDresence  of  an  endometritis  more  probably  indicates 
a  possible  purulent  salpingitis  than  a  hydrosalpinx. 

As  generally  happens  in  any  case  of  pelvic  inflammation,  men- 
strual disturbance  is  often  present  in  hydrosalpinx;  the  flow  is  gen- 
erally too  frequent  and  is  increased  in  quantity. 

In  hydrosalpinx,  constitutional  symptoms  may  be  entirely  absent. 
The  temperature  is  normal  or  only  slightly  elevated,  the  patient  may 
have  a  good  appetite  and  may  feel  well.  She  may  be  able  to  perform 
her  daily  duties  and  live  in  comfort.  At  other  times,  however,  exertion 
may  bring  on  pain  in  the  pelvic  region  on  one  side  or  on  both. 

Diagnosis. — It  would  seem  that  a  diagnosis  of  hydrosalpinx  should 
be  easily  made  after  a  careful  physical  examination.  As  a  matter  of 
fact,  this  is  true  in  some  cases.  When  we  find  a  kidney-shaped 
tumour,  generally  unilateral,  in  the  position  normally  occupied  by  the 
Fallopian  tube  and  near  the  ovary,  we  may  feel  quite  certain  that  we 
have  to  deal  with  a  salpingitis.  Again,  since  the  tube  is  normally 
divided  into  compartments,  when  we  find  this  sausage-shaped  tumour 
sacculated,  we  may  conjecture  with  great  probability  that  we  have  a 
tube  which  is  distended  with  fluid,  whether  it  be  serum  or  blood,  and 
consequently  we  may  make  a  diagnosis  of  hydrosalpinx  or  hematosal- 
pinx. And  yet,  even  after  we  have  decided  that  the  tumour  present 
is  part  of  a  distended  tube,  we  shall  often  remain  in  doubt  as  to  the 
exact  character  of  its  contents.     As  a  rule,  however,  in  hydrosalpinx 


506  A  TEXT-BOOK  OF   GYNECOLOGY 

the  walls  of  the  tumour  are  thin  and  the  mass  gives  to  the  finger  a 
sense  of  elasticity,  the  degree  of  which  is  largely  dependent  upon  the 
size  of  the  growth  and  the  consequent  thinness  of  the  walls.  The 
lack  of  adhesions  is  always  an  important  factor,  and  mobility  of  the 
tumour  is  more  characteristic  of  a  hydrosalpinx  than  of  a  pyosalpinx. 
When,  however,  the  tube  is  greatly  distended,  the  tumour  takes  on  a 
rounded  form  and  resembles  more  an  ovarian  cyst. 

The  other  principal  conditions  liable  to  be  confused  with  a  hydro- 
salpinx are  small  ovarian  or  parovarian  cysts,  hematosalpinx,  and  ex- 
trauterine pregnancy.  A  typical  hydrosalpinx  is  movable,  sausage- 
like, or  reniform  in  shape,  and  its  course  can  be  followed,  as  it  comes 
off  from  the  uterus,  in  the  position  occupied  normally  by  the  tube. 
The  ovarian  tumour  or  cyst  is  rounded  and  separated  from  the  body  of 
the  uterus.  A  parovarian  cyst  may  be  movable,  but  it  is  more  usually 
of  a  rounded  than  of  an  elongated  form. 

Extra-uterine  pregnancy  is  distinguished  by  the  history  and  by 
various  signs  pointing  to  pregnancy.  Again,  as  has  been  said,  sal- 
pingitis causes  dysmenorrhoea  more  often  than  amenorrhoea;  and  the 
latter,  together  with  enlargement  of  the  breasts  and  other  more  or  less 
definite  symptoms,  should  always  suggest  a  possible  ectopic  pregnancy. 
Later,  rupture  with  the  classic  symptoms  of  internal  hemorrhage  makes 
the  latter  diagnosis  certain.  With  respect  to  the  diagnosis  between 
hydrosalpinx,  hematosalpinx,  and  pyosalpinx,  more  will  be  said  later. 

Hematosalpinx. — Here,  instead  of  a  serous  fluid,  we  have  a  sacto- 
salpinx  containing  blood.  As  a  rule,  the  symptomatology  and  physical 
signs  are  much  the  same  in  both  conditions.  The  tumour  is  in  the 
same  position  and  of  the  same  shape  as  a  hydrosalpinx. 

Hematosalpinx,  except  as  a  result  of  tubal  pregnancy,  is  simply  a 
hydrosalpinx  into  which  a  hemorrhage  has  occurred,  and  naturally 
therefore  in  its  simple  form  is  a  rarer  condition  than  hydrosalpinx. 
Various  tables  are  found  in  text-books  showing  the  important  distin- 
guishing points.  But,  when  all  has  been  said,  the  fact  remains  that  as 
a  rule  neither  the  history  nor  the  symptomatology  affords  a  sufficient 
basis  for  a  positive  diagnosis  between  these  two  closely  allied  conditions. 

Pyosalpinx. — AAHien  a  purulent  focus  exists  in  either  one  or  both 
tubes  the  process  often  extends  to  the  ovaries  or  the  pelvic  peritoneum. 
The  symptoms  vary  according  to  the  intensity  and  extent  of  the  in- 
fective process.  In  the  acute  stage,  which  lasts  a  week  or  more,  the 
pain  is  intense.  The  patient  lies  in  bed  with  the  knees  drawn  up  and 
looks  and  feels  very  ill.  The  pain  complained  of  is  sometimes  localized, 
but  it  m^^st  be  remembered  that,  without  any  general  peritonitis  the 
pain  and  tenderness  may  be  diffuse  and  may  be  referred  over  the  whole 
abdominal  region. 

The  temperature  ranges  from  100°  to  105°  F.;  the  pulse  is  rapid, 
100  to  120;  when  pus  is  present,  the  patient  frequently  complains  of 
chills  or  chilly  feelings,  and  she  may  also  suffer  from  sweats.  The 
abdomen  is  tense  and  tender,  sometimes  sufficiently  so  to  suggest  the 


INFECTIONS  AND   INFLAMMATIONS  OF   FALLOPIAN  TUBES    507 

presence  of  a  general  jDeritonitis,  although  in  reality  the  process  may 
be  more  or  less  strictly  localized. 

In  favourable  cases,  after  a  few  days  the  temperature  becomes  lower, 
although  it  may  still  be  one  or  two  degrees  above  normal  with  remis- 
sions. The  pulse  rate  remains  slightly  above  the  normal.  In  such 
cases  the  patient  may  often  be  able  to  get  about,  but  every  now  and 
then  she  will  have  a  setback  and  suffer  for  a  few  days  from  high  fever 
and  pain,  after  which  the  temperature  falls  again.  These  relapses  are 
probably  due  to  the  escape  of  a  small  amount  of  pus  from  the  abscess 
with  a  resulting  peritonitis.  When  a  large  abscess  ruptures  suddenly 
a  general  peritonitis  may  be  set  up,  and  unless  prompt  operative  in- 
tervention occurs,  the  result  is  likely  to  be  fatal. 

This  recurrence  of  attacks  may  go  on  for  years.  The  patient  is 
never  well,  and  at  intervals  is  dangerously  ill.  Such  cases  have  often 
been  cured  by  removal  of  the  pus  sacs. 

In  cases  of  gonorrhoeal  salpingitis,  we  can  often  obtain  a  history  of 
a  sudden  attack  of  vulvitis  or  vaginitis  which  has  sooner  or  later  been 
followed  by  abdominal  pain.  It  may,  however,  be  difficult  to  obtain 
so  direct  a  history  from  the  patient,  as  it  may  be  months  or  years  before 
she  comes  to  us  with  symptoms  referable  to  the  tubes  or  pelvic  perito- 
neum. Many  patients  give  no  history  of  gonorrhoea,  but  they  may  com- 
plain that  they  have  been  suffering  for  some  weeks  or  months  from  pain 
in  the  lower  part  of  the  abdomen  with,  perhaps,  painful  micturition 
and  defecation.  They  may  also  tell  us  that  they  think  they  have  had 
fever,  and  that  at  intervals  they  have  had  chilly  sensations  or  definite 
rigors.  Despite  the  length  of  their  illness,  however,  we  may  find 
them  with  fair  appetites,  little  or  no  fever,  and,  generally  speaking,  in 
excellent  condition  except  for  the  local  symjatoms. 

A  streptococcous  infection  generally  dates  from  a  labour,  an  abor- 
tion, or  local  treatment.  It  is  usually  ushered  in  with  a  chill  and 
the  fever  rises  rapidly.  This  continues  for  some  days,  and  the  pinched 
look  and  anxious  expression  of  the  patient  show  very  visibly  the 
effects  of  the  absorption  of  septic  material.  Abdominal  tenderness 
and  distention  are  marked.  After  the  acute  stage  has  passed,  the 
patient  may  get  out  of  bed,  but  she  usually  still  has  a  septic  tempera- 
ture and  hardly  ever  attains  the  relative  health  of  the  gonorrhceal 
cases. 

Obstinate  constipation  is  sometimes  present,  usually  because  the 
patients  fear  to  have  a  stool  on  account  of  the  severe  pains  that  are 
excited  by  the  efforts.  Occasionally  partial  or  complete  obstruction  is 
caused  by  bands  of  inflammatory  tissue  stretched  across  and  confining 
the  lumen  of  the  bowel  (Fig.  214). 

Painful  micturition  is  not  likely  to  be  present  when  the  purulent 
process  is  confined  to  the  tube;  often,  however,  the  bladder  is  pressed 
upon  by  the  inflammatory  mass  or  becomes  infected  with  the  specific 
poison  (Fig.  215).  In  the  most  favourable  cases,  if  not  submitted  to 
operation,  weeks  or  months  elapse  before  the  poison  has  worn  itself 


508 


A   TEXT-BOOK   OP   GYNECOLOGY 


out.     Only  in  rare  instances  does  the  patient  regain  complete  health, 

and  then,  as  a  rule,  only  after  months  of  suffering  and  inconvenience. 
After  the  disease  has  become  subacute,  the  symptoms,  though  less 

severe,  are  still  present,  and  exacerbations  may  occur  from  time  to  time. 

A  persistent  suppurative  process  in  the  tube  or  in  the  pelvic  perito- 
neum gives  rise  to  vari- 
ous pains,  especially  to 
a  bearing -down  feeling, 
headache,  backache, 
often  to  a  chronic  puru- 
lent discharge,  and  some- 
times to  painful  micturi- 
tion and  defecation.  A 
gonococcous  infection 
often  wears  itself  out  in 
this  way. 

Exacerbations  occur 
with  a  sudden  rise  of 
temperature,  which  in- 
dicates that  there  is  a 
further  lighting  up  of  the 
process  or  that  it  has  ex- 
tended into  the  perito- 
neum. Sometimes  all 
the  signs  of  a  general 
peritonitis  appear,  and 
the  prognosis  in  these 
cases  is  grave. 

In  the  diagnosis  of 
suppurative  processes  in 
the  tubes  the  history  ■  is 
of  great  importance.  If 
the  patient  dates  her  ill- 
ness from  an  acute  attack 
with  the  symptoms  be- 
fore mentioned,  begin- 
ning after  a  labour  or  an 


Fig.  214. — "Occasionally  partial  or  nuiiiilcte  obstruction 
is  caused  by  bands  of  inflammatory  tissue  stretched 
across  and  confining  the  lumen  of  the  bowel." — Robb 
(page  507). 


abortion,  or  during  the 
course  of  local  treatment  to  the  uterus,  a  streptococcous  infection  is 
strongly  to  be  suspected.  Some  patients  will  give  a  clear  history  of  a 
preceding  gonorrhoea,  while  from  others,  careful  questioning  will  elicit 
an  account  of  an  attack  of  vaginitis  which  we  may  safely  put  down  as 
of  gonorrhoeal  origin. 

In  still  other  cases,  no  date  can  be  assigned  by  the  patient  to  the 
onset  of  the  disease,  which  has  come  on  insidiously.  Leucorrhcea  may 
have  been  noticed  for  some  time,  with  increasing  pain  at  the  menstrual 
period,  or  perhaps  menorrhagia.     The  patients  who  are  suffering  with 


INFECTIONS   AND   INFLAMMATIONS  OF   FALLOPIAN   TUBES    509 

a  pelvic  peritonitis  are  generally  in  a  much  worse  condition  than  those 
in  whom  the  suppurative  process  is  limited  to  the  tubes.  But  much 
variation  may  be  looked  for.  Some  women,  despite  the  existence  of  a 
localized  suppurative  process,  look  well  and  robust  though  they  com- 
plain of  pain  at  times;   while  others  are  completely  broken  down,  and 


Fig.  215. — "Often  the  blaJdci  i^  pitb&td  upon  b}  tliL  mllauunatory  mass  or  becomes  infected 
with  the  specific  poison." — Robb  (page  507). 

show  in  their  faces  and  in  their  general  behaviour  that  they  are  chronic 
invalids.  Some  are  without  pain  so  long  as  they  sit  still  or  lie  down, 
but  the  slightest  movement  or  jarring  may  evoke  severe  suffering. 
When  the  pelvic  abscess  is  situated  elsewhere  than  in  the  tubes,  the 
diagnosis  by  means  of  the  physical  examination  taken  in  conjunction 
with  the  symptoms  of  pain,  chill,  fever,  and  rapid  pulse,  is  compara- 
tively easy,  especially  when  the  attack  has  followed  parturition  or 
abortion.  When  a  mass  is  felt  which  bulges  out  the  vault  of  the  vagina 
and  is  very  tender  to  the  touch  and  fluctuates,  we  may  safely  conclude 
that  we  are  dealing  with  suppuration  of  the  tube  or  ovary,  or  both, 
with  pelvic  peritonitis.  When  the  inflammation  has  been  mainly  con- 
fined to  the  tubes  the  diagnosis  is  more  difficult,  but  it  will  often  be 
possible  to  feel  a  mass  coming  off  from  the  side  of  the  uterus  and, 
though  intimately  connected  with  it,  having  a  mobility  of  its  own. 
On  attempting  to  move  the  mass  we  find  it  possible  to  do  so  to  a  slight 
extent,  unless  it  has  been  bound  down  too  firmly  with  peritonitic  ad- 
hesions. Sometimes  a  mass  is  found  on  either  side  of  the  uterus,  and 
in  these  cases  we  may  be  confident  that  there  is  tubal  or  tubo-ovarian 
disease  on  both  sides.  It  is  not  always  possible  to  recognise  the  pres- 
ence of  pus  by  pal])ation,  since  fluctuation  may  not  be  obtainable  owing 


510 


A  TEXT-BOOK  OF   GYNECOLOGY 


to  the  thickening  of  the  walls  of  the  tube  and  the  dense  adhesions. 
Sometimes,  however,  Avhen  on  gentle  palpation  the  tumour  has  ap- 
peared to  be  solid,  by  manipulating  the  external  and  internal  fingers 
so  that  the  tumour  is  brought  between  them,  a  very  distinct  sensation 
of  fluctuation  can  be  obtained. 

Again  it  must  be  remembered  that  in  not  a  few  cases  of  pyosalpinx 
there  are  only  a  few  drops  of  pus  in  the  tube. 

In  making  a  diagnosis  of  pyosalpinx  the  history  is  of  great  assist- 
ance, and  it  is  often  also  of  service  in  determining  the  etiology  of  the 
suppurative  process. 

The  following  data  liave  been  given  b}^  Kelly  to  aid  in  the  diagnosis 
between  a  pyosalpinx  of  gonorrhceal  and  one  of  a  streptococcous  origin: 


GONORRHCEAL   TXFECTION 

Slow  in  its  onset,  often  preceded  by  in- 
flammation of  the  external  genitals 
and  urethra. 

Pain  localized  in  one  or  both  ovarian 
regions. 

No  signs  of  general  peritonitis. 

Suffers  more  or  less  constantly,  but  may 
have  no  fever. 

Temperature  98.5°  to  102°  F.  (38.9°  C). 

Pulse   accelerated,  but  of  good  quality 

and  volume. 
Attack  lasts  from  five  to  fifteen  days. 


Often  presents  the  appearance  of  good 
health. 

Gonococci  usually  found  in  coverslip  prep- 
arations from  the  cervical,  urethral,  or 
vulvo-vaginal  glandular  secretions. 

History  of  marital  gonorrhoea. 


Streptococcous  Infection 

Onset  abrupt,  following  miscarriage,  nor- 
mal labour,  or  topical  treatments. 

Pain    more    general   and   severe   in   the 

lower  abdomen. 
Usually  signs  of  peritonitis. 
Suffers    constantly,   and    usually   has    a 

septic  fever. 
Temperature   101°   to   105°   F.   (38.3°   to 

40.5°  C). 
Pulse  feebler  and  moi'e  rapid. 

Attack  seldom  lasts  less  than  a  month, 
and  may  continue  three  months  or 
more. 

Anaemic  and  weak. 

Gonococci  not  found  in  the  secretions. 


Husband  sound. 


Pj^osalpinx  is  sometimes  confused  with  ai^i^endicitis  and  other  con- 
ditions to  which  we  have  already  referred.  As  points  serving  to  distin- 
guish pyosalpinx  from  hydrosalpinx,  Dudley  gives  the  following: 


Hydrosalpinx 
Systemic  disturbance  relatively  slight. 

Less  fever,  pain,  and  adhesions. 
Bursting  of  the  tube  and  discharge  of  its 

contents  into  the  abdomen  may  give 

relief. 
Walls  of  the  tube  distended,  thin,  smooth, 

elastic,  and  fluctuating. 


Pyosalpinx 

Systemic  infection  often  marked  from 
absorption  of  pus. 

More  fever,  pain,  and  adhesions. 

Bursting  of  the  tube  and  discharge  of  its 
contents  may  cause  dangerous  perito- 
nitis. 

Walls  of  the  tube  thick,  hard,  sometimes 
stony,  resistant,  nodular,  less  elastic, 
and  less  fluctuating. 


INFECTIONS   AND   INFLAMMATIONS   OF   FALLOPIAN   TUBES    511 

Hydrosalpinx  Pyosalpinx 

More  usually  associated   with   catarrhal  More   usually  associated  with   purulent 

endometritis.  endometritis. 

Thin,  overstretched  tubal  wall  easily  rup-  Walls  usually  not  so  easily  ruptured. 

tured. 

It  may  be  said  that  a  hydrosalpinx,  while  often  very  elastic,  on 
acount  of  the  great  distention  does  not  give  fluctuation.  Sometimes 
the  wall  of  a  pyosalpinx,  instead  of  being  thickened,  is  as  thin  as  that 
of  a  hydrosalpinx.  Great  care  should  be  exercised  during  the  examina- 
tion not  to  rupture  any  fluctuating  tumour  that  may  be  found,  as,  by 
so  doing,  the  risk  is  run  of  infecting  the  whole  peritoneal  cavity.  In 
some  cases  a  pyosalpinx  forms  a  large  tumour  projecting  above  the 
symphysis,  or  more  commonly  toward  one  or  other  groin  Just  above 
Poupart's  ligament.  With  the  history  and  combined  internal  and  ex- 
ternal examination,  the  existence  of  a  suppurative  process  can  be  deter- 
mined, but  often  only  an  operation  can  decide  its  exact  nature,  whether 
it  is  a  suppurating  cystoma  of  the  ovary  or  a  pyosalpinx. 

Tuherculoiis  Salpingitis. — In  secondary  tuberculosis  of  the  adnexa, 
the  sym|)toms  are  usually  masked  by  those  arising  from  the  tuberculous 
process  elsewhere  in  the  body.  Although  the  possibility  of  a  primary 
tuberculous  process  in  the  tubes  should  always  be  borne  in  mind,  ex- 
perience has  taught  that  there  is  nothing  in  the  symptomatology  char- 
acteristic of  the  condition.  Even  at  the  time  of  operation  it  has  again 
and  again  escaped  detection  and  has  only  been  discovered  later  by  the 
aid  of  the  microscope. 


CHAPTEE  XXXIV      . 

INDIVIDUAL  INFECTIONS   OF   THE   FALLOPIAN   TUBES 

Infections  by:  (a)  Gonococcus;  (&)  streptococcus ;  {c)  Bacillus  tuberculosis;  {d)  Bacil- 
lus coli  communis ;  (e)  pneumococcus ;  (/)  staphylococcus ;  {g)  saprophytes ;  Qi) 
septic  vibrion  ;  (i)  actinomyces. 

Individual  infections  of  the  Fallopian  tubes  are,  many  of  them, 
yet  in  course  of  preliminary  investigation.  Those  whicli  have  been 
determined  with  reasonable  accuracy  and  which,  consequently,  will  be 
considered,  although  briefly,  in  this  work,  depend  upon  (a)  the  gono- 
coccus,  {b)  the  streptococcus,  (c)  the  Bacillus  tuberculosis,  (d)  the  Bacil- 
lus coli  communis,  (e)  the  pneumococcus,  (/)  the  staphylococcus,  (g)  the 
saprophytes,  (h)  the  septic  vibrion,  (i)  the  actinomyces. 

Gonococcous  Infection  of  the  Fallopian  Tubes. — Infection  by  the 
gonococcus  of  Xeisser  (see  Micrococcus  Gonorrhoese),  according  to  the 
general  consensus  of  competent  observers,  is  responsible  for  a  majority 
of  purulent  accumulations  within  the  tubes  and  for  those  inflamma- 
tory changes  which  are  induced  thereby.  This  infection  of  the  female 
genitalia,  more  conspicuously  than  any  other,  may  be  designated  as 
of  the  ascending  type;  by  which  is  meant  that  an  infection  beginning 
externally  or  within  the  vagina,  gradually  travels  upward,  chiefly,  if 
not  exclusively,  by  progressive  invasion  of  the  mucous  surface  until 
it  reaches  the  Fallopian  tubes.  There  remain,  however,  some  unex- 
jDlained  facts  in  connection  with  this  phenomenon:  thus,  gonococcous 
infection  of  the  vulva  and  vagina  is  not  uncommon  among  children  (see 
Infections  of  the  External  Genital  Organs);  yet  pus  tubes  are  prac- 
tically unknown  in  childhood.  Of  course,  the  immature  development 
of  the  uterus  before  ]3uberty  offers  a  certain  physical  barrier  to  the 
upward  extension  of  this  afl'ection  in  children;  but  it  would  seem 
that  at  least  occasional  instances  would  be  forthcoming  in  which  the 
obstacle  had  been  overcome.  There  is  a  strong  probability  that  in- 
vestigation will  establish  the  fact  that  the  uterine  mucosa  of  childhood 
with  its  dearth  of  epithelium  is  an  uncongenial  soil  for  this  micro- 
coccus. With  the  develo]3mental  impulses  which  come  at  puberty,  how- 
ever, these  conditions  are  changed,  and  there  are  established  a  certain 
luxuriance  of  epithelium  and  a  certain  deepening  of  the  utricular  folds 
which  are  favourable  to  the  propagation  of  the  germs  of  gonorrhoea. 
(vSee  Infections  of  the  Uterus.) 
513 


INDIVIDUAL   INFECTIONS  OP   THE   FALLOPIAN   TUBES       513 

Gonococci  in  the  Fallopian  tubes  are  found  in  the  pus  and  upon  the 
sui-face  of  the  mucous  membrane.  They  have  been  reported  as  being 
observed  in  the  deeper  layers  of  the  tubes,  but  these  observations 
have  been  seriously  questioned  by  competent  observers.  Westermark 
was  the  first  to  demonstrate  the  organism  in  intratubal  pus.  His  ob- 
servations have  been  confirmed  by  Orthmann,  Zweifel,  Witte,  Doder- 
lein,  Schauta,  Morax,  and  numerous  other  observers  in  various  coun- 
tries. It  is  not  always  demonstrable  in  this  medium.  Eeymond  reports 
the  observations  of  nine  investigators,  who  have  demonstrated  the  pres- 
ence of  gonococcus  in  tubal  pus  78  times  in  399  cases.  The  fact  that 
it  is  not  present  in  the  pus  of  a  given  case  at  a  given  time  is  not  to 
be  construed  as  evidence  that  it  was  not  the  essential  element  of  in- 
fection, for  these  micro-organisms  perish  in  their  own  toxines,  and 
thus  disappear  from  the  pus  for  the  existence  of  which  they  are  respon- 
sible. Gonorrhoeal  pus  of  recent  intratubal  origin  reveals  leucocj^tes  of 
increased  size,  which  contain  groups  of  gonococci  and  epithelial  cells 
also  enlarged  and  inclosing  the  same  micro-organism.  A  limited  num- 
ber of  free  gonococci  are  generally  observable.  Many  observers  have 
failed  to  find  the  gonococci  in  the  mucous  membrane  in  cases  in  which 
their  presence  has  been  demonstrated  in  the  pus.  This,  as  suggested 
lay  Eeymond,  is  probably  due  to  defective  methods  of  staining.  Gram's 
method  is  generally  employed,  but  recent  investigators  have  been 
able  to  demonstrate  the  presence  of  the  gonococcus  by  the  methylene 
blue  and  pure  tannin  method  of  NicoUe,  after  failing  to  find  it  by 
Gram's  method.  In  a  section  prepared  in  this  way  by  Morax  there 
•are  observable,  a  layer  of  piis  adhering  to  the  mucous  surface; 
leucocytes  in  the  stroma  of  the  mucosa;  numerous  epithelial  cells  that 
liave  lost  their  positions,  form,  and  dimensions,  but  contain  no 
gonococci;  and,  finally,  both  leucocytes  and  detached  epithelial  cells, 
which  do  contain  gonococci.  A  distinguishing  feature  of  these 
changes  is  that  the  epithelium  is  not  thrown  off  en  Hoc,  but  the  cells 
are  shed  individually.  This  manner  of  desqviamation  is  the  exact  re- 
verse of  that  which  occurs  in  streptococcous  infection.  (See  Strepto- 
coccous  Infection  of  the  Fallopian  Tubes).  The  fimbriae  are  studded 
with  migrated  leucocytes;  the  surface  of  the  epithelium,  says  Reymond, 
is  covered  with  a  purulent  layer,  which  is  composed  of  a  large  number 
of  leucocytes  and  detached  epithelial  cells.  It  is  in  this  superimposed 
stratum  that  the  gonococci  are  readily  discoverable,  not  only  in  the 
epithelial  cells  and  in  the  leucocytes,  but  lying  quite  free  between  the 
cells.  It  seems  that  these  micro-organisms  but  rarely  invade  the  epi- 
thelial cells  which  remain  in  situ,  while  the  leucocytes  which  lie  be- 
tween the  epithelial  cells  are  likewise  but  rarely  invaded.  Competent 
observers  have  failed  to  discover  the  gonococci  deeper  than  the  adven- 
titious layer  that  has  just  been  described,  although  Wertheim  asserts 
that  he  has  found  them  in  deeper  structures.  In  this  infection  the 
muscularis  is  always  engorged,  its  vessels  being  apparently  multiplied 
in  niirnbor  find  inci'oased  in  calibre,  while  the  lymphatics  are  filled  with 


514  A  TEXT-BOOK  OF  GYNECOLOGY 

leucocytes  in  course  of  migration  to  the  mucous  surface.  The  gono- 
cocci  are  not  demonstrable  in  the  muscularis,  or  within  the  leucocytes 
in  that  tunic.  Wertheim's  statement,  cautiously  made  to  the  con- 
trary, lacks  confirmation,  his  alleged  observation  being  explained  by 
other  investigators  as  due  rather  to  defective  methods  of  staining  than 
to  the  actual  detection  of  the  micro-organisms.  The  inflammatory 
changes  induced  within  the  deep  layers  of  the  tube,  however,  and, 
particularly,  the  infiltration  which  occurs  at  the  vestibule,  are  sufficient 
to  cause  an  inflammation  of  the  peritoneum,  with  resulting  exudation 
and  occlusion  of  the  distal  ostium  of  the  tube.  (See  Infections  of  the 
Peritoneum.)  Nevertheless,  the  gonococci  themselves  have  been  dem- 
onstrated on  the  peritoneal  surface  in  these  cases,  both  Gushing  and 
Michaelis  having  reported  instances  of  undoubted  accuracy.  It  is 
probable  that  the  explanation  of  this  circumstance  is  to  be  found  in 
the  escape  of  the  micro-organisms  from  the  lumen  of  the  tube  be- 
fore the  closure  of  the  vestibule.  (See  Morbid  Histology  of  Salpin- 
gitis.) 

The  route  by  which  the  gonococcus  travels  from  the  seat  of  primary 
infection  to  the  tubes,  has  been  a  source  of  speculation,  which  has,  as 
yet,  brought  forth  no  definite  conclusions.  There  are  those  who  con- 
tend that  it  travels  by  progressive  invasion  of  the  mucous  surfaces,  by 
direct  passage  through  the  tissues,  and  by  traversing  the  circulatory 
systems,  respectively.  Each  of  these  three  hypotheses  has  its  advo- 
cates. That  the  mucous  surfaces  from  the  ostium  vaginae  to  the  tubes 
are  progressively  invaded,  seems  to  rest  upon  ample  testimony.  It  is 
exceedingly  probable  from  the  observations  of  Camescasse,  Eosthorn, 
and  others,  that,  in  the  presence  of  a  vaginal  infection,  the  uterus  is 
invaded  in  a  much  larger  percentage  of  cases  than  was  formerly  sup- 
posed; while  Steinschneider,  after  finding  the  gonococcus  present  in 
the  cervix  in  every  one  of  34  consecutive  cases  of  vaginal  infection, 
concludes  that  the  invasion  of  the  endometrium  is  a  universal  incident 
of  gonorrhoea  in  women.  While  this  conclusion  is  certainly  too  sweep- 
ing to  be  justified  by  the  observations  upon  which  it  is  based,  it  is 
nevertheless  to  be  looked  upon  as  one  of  great  significance.  The  be- 
haviour of  the  gonococcus  on  the  epithelial  surfaces  indicates  that  they 
offer  to  it  the  avenue  of  least  resistance  for  its  migration;  and  that, 
once  within  the  uterus,  and  within  the  utricular  folds  of  the  endo- 
metrium, there  is  nothing  to  keep  it  from  extending  its  invasion  to  the 
tubal  epithelium. 

There  seem  to  be  ample  grounds  for  doubting  that  the  gonococcus 
invades  the  deeper  tissues  without  reference  to  circulatory  media  of 
communication.  The  fact,  however,  that  it  does  reach  the  circulation, 
both  sanguineous  and  lymphatic,  rests  upon  indisputable  evidence. 
Blumer,  Thayer,  and  Lazear  have  cultivated  it  from  the  blood,  while 
Flexner  has  demonstrated  it  at  autopsy  in  lesions  of  ulcerative  endo- 
carditis. The  latter  observer  states  that  the  endocarditides  associated 
with  gonorrhoea,  are  commonly  caused  by  the  gonococcus,  and  that,  in 


INDIVIDUAL   INFECTIONS  OP  THE   FALLOPIAN   TUBES       515 

these  cases,  a  general  infection  with  the  micro-organism  may  take  place. 
Inflammations  of  the  pleura  and  pericardium,  and  supj^urative  myo- 
carditis, have  been  caused  by  it.  These  facts  establish  beyond  question 
that  the  gonococcus  may  invade  the  blood  and  be  carried  by  that 
medium  to  remoter  parts  of  the  system.  The  common  clinical  phe- 
nomenon of  suppuration  of  the  inguinal  glands  (gonorrhoeal  buboes) 
in  cases  of  acute  gonorrhoea,  shows  the  possibility  of  invasion  of  the 
lymph  channels,  while  pelvic  lymphangeitis,  of  similar  origin,  has  a 
similar  significance.  These  facts  being  established,  it  follows  that  the 
contention  of  Eeymond  and  Magill,  that  the  gonococcus  does  not  travel 
from  the  seat  of  primary  infection  to  the  tubes  through  either  the 
lymph  or  the  blood  channels,  is  not  supported  by  analogy.  If  it  is 
granted  that  the  blood  vessels  may  be  invaded  by  this  micro-organism, 
and  that  the  lymphatics  may  likewise  become  the  media  of  infection, 
it  would  seem  that  subepithelial  structures  are  liable  to  invasion 
through  these  avenues.  The  controversy  between  Wertheim,  on  the  one 
hand,  and  Eeymond,  on  the  other,  and  between  their  respective  fol- 
lowers, touching  this  point,  can  only  be  settled  in  the  light  of  further 
direct  observations. 

The  symptoms  of  gonococcous  infection  of  the  tubes  are  not  specially 
distinctive.  The  infection  may  follow  either  a  virulent  acute  infection 
of  the  external  genitalia,  or  it  may  be  the  result  of  a  primary  infec- 
tion, so  mild  in  character  as  to  have  escaped  attention.  The  interval 
between  a  known  primary  infection  and  the  manifestation  of  the 
disease  in  the  tube,  may  be  so  great  that  the  connection  between  the 
two  may  not  be  recognised.  The  natural  history  of  the  micro-organism 
and  its  pathogenic  characteristics,  is  such  that  its  activities  are  inter- 
rupted, and  the  patient  may  enjoy  periods  more  or  less  prolonged  of 
symptomatic  health.  When  invasion  of  the  tubes  has  taken  place,  how- 
ever, there  is  generally  an  initial  chill,  which  may  be  very  slight,  fol- 
lowed by  an  elevation  of  temperature,  which  may  not  go  above  100°  F.; 
while,  on  the  other  hand,  these  symptoms  may  be  very  intense.  Pain 
is  complained  of  at  the  base  of  each  lower  quadrant  of  the  abdomen. 
This  pain  may  be  either  sharp  or  lancinating,  or  it  may  be  pulsating 
and  may  radiate  into  the  lumbar  region,  or  find  expression  in  the 
sacral  plexus  or  along  the  sciatic  nerve.  The  pain  is  increased  on 
external  pressure  or  by  the  concussion  incident  to  walking.  Bimanual 
examination  will  reveal  foci  of  tenderness  in  the  neighbourhood  of 
one  or  both  Fallopian  tubes,  which  will  generally  be  found  large  and 
cedematous.  These  symptoms  may  be  interrupted  by  a  discharge  of 
pus,  either  through  the  uterus  or  the  intestine,  followed  by  a  period 
of  apparent  cure.  Their  return,  however,  is  only  a  matter  of  time. 
The  actual  diagnosis  of  gonococcous  infection  can  be  based  only  upon 
a  demonstration  of  the  micro-organism  in  the  pus.  (See  Diagnosis  of 
Inflammatory  Diseases  of  the  Uterine  Appendages.) 

Tbc  treatrnxnt  of  gonococcous  infection  is  given  under  the  head  of 
Treatment  of  Infections  of  the  Fallopian  Tubes. 


516  A  TEXT-BOOK  OF   GYNECOLOGY 

Streptococcous  Infection  of  the  Fallopian  Tubes. — Infection  of  the 
FallojDian  tubes  by  the  Streptococcus  pyogenes  generally  occurs  as  an 
acute  virulent  inflammation — although  this  micro-organism  is  some- 
times present  when  least  suspected  in  the  more  chronic  forms  of  pyo- 
salpinx.  Eeymond  and  Magill,  in  their  masterly  contribution  upon 
this  subject  {Annals  of  Surgery,  1896),  state  that  they  found  the 
streptococcus  in  these  cases  only  with  difficulty.  It  would  not  respond 
to  the  culture  tests  made  with  ordinary  media  until  after  it  had  been 
revitalized,  as  it  were,  by  successive  inoculations.  It  would  seem  that 
the  diminution  in  the  virulence  of  the  micro-organisms  in  some  of 
these  cases,  accounts  for  the  chronicity  of  s3anptoms  following  its 
entrance  into  the  tubes.  These  authors,  in  a  number  of  their  cases, 
were  unable  to  detect  the  presence  of  streptococci  until  after  they  had 
made  repeated  observations  in  cases  which  would  ordinarily  have  been 
designated  as  sterile  salpingitis.     (See  Streptococcus  Pyogenes.) 

The  symptoms  of  streptococcous  infection  of  the  Fallopian  tubes  are 
to  be  studied  in  the  light  of  the  fact  that,  in  the  chain  of  morbid  events, 
the  invasion  of  the  tubes  always  occurs  secondarily  to  invasion  of  the 
uterus.  While  this  is  true,  an  equally  important  fact  to  be  remembered 
is,  that  invasion  of  the  tubes  occurs  so  promptly  after  the  primary 
infection  of  the  uterus  that  the  symptomatology  of  the  two  conditions 
is,  in  the  majority  of  cases,  essentially  coincident.  It  is  only  in  those 
cases  in  which  the  micro-organisms  seem  to  have  a  diminished  viru- 
lence, and  in  which  the  symptoms  of  uterine  infection  have  subsided, 
that  there  are  presented  any  distinct  signs  of  involvement  of  the  Fal- 
lopian tubes;  for,  in  the  presence  of  acute  streptococcous  infection 
of  the  uterus  with  associated  involvement  of  the  lymphatics  and  gen-- 
eral  engorgement  of  the  pelvic  tissues,  the  condition  of  the  tubes  is, 
as  a  rule,  completely  masked.  The  demonstrated  existence  of  strepto- 
coccous infection  of  the  uterus  and  of  the  surrounding  structures  may, 
however,  be  accejited  of  itself  as  a  symptom  of  involvement  of  the 
tubes.  It  is  true  that  in  a  limited  number  of  cases  this  rule  may 
fail,  but  even  then  it  remains  the  safer  guide  for  the  treatment  of 
the  case.  The  constitutional  symptoms  of  this  form  of  infection  are, 
in  effect,  those  of  similar  infection  of  the  uterus.  (See  Streptococcous 
Infection  of  the  Uterus.)  In  a  few  instances  the  diagnosis  may  be 
confirmed  by  i^alpation  of  the  enlarged  tubes  by  bimanual  manipula- 
tion; but  it  should  be  remembered  that  this  is  a  dangerous  expedient, 
as  even  slight  manipulation  may  result  in  forcing  some  of  the  virulent 
pus  from  the  tube  into  the  peritoneum.  The  use  of  the  aspirating 
needle  for  diagnostitial  purposes  in  these  acute  cases  is  an  even  more 
dangerous  procedure.  The  fact  of  a  recent  puerperal  infection,  the 
history  of  streptococcous  invasion  of  the  uterus,  and  the  demonstrated 
existence  of  large  tubes,  are  facts  upon  which  a  presumptive  diagnosis 
may  safely  be  based.  The  isolation  of  the  streptococcus  by  microscopic 
examination  and  by  culture  and  inoculation  experiments,  will  clear  up 
any  remaining  doubts  as  to  the  character  of  the  disease. 


INDIVIDUAL   INFECTIONS   OP   THE   FALLOPIAN   TUBES       517 


The  pathology  of  salpingitis  of  streptococcous  origin  in  its  general  fea- 
tures is  not  unlike  that  already  given.  (See  Morbid  Histology  of  Sal- 
pingitis.) The  morbid  processes  established  by  the  streptococcus  and 
the  behaviour  of  the  micro-organism  itself,,  however,  present  some 
features  that  call  for  special  mention.  The  thorough  studies  of  this 
subject  by  Eeymond  and  Magill  (Ihid.),  upon  which  this  chapter  is 
largely  based,  show  that  the  pus  from  the  tubes  contains  a  relatively 
small  number  of  leucocytes,  but  a  great  quantity  of  eliminated  de- 
formed epithelial  cells,  whose  perinuclear  protoplasm  has  often  been 
lost.  There  are  also  present  cells  from  a  deeper  layer,  which  seem 
to  have  fallen  from  the  frame  of  the  fringes.  The  streptococci  are 
rarely  in  the  leucocytes,  more  frequently  in  the  epithelial  cells,  but 
most  frequently  between  the  cells.  A  slide  mounted  with  the  pus 
of  streptococcous  salpin- 
gitis from  one  of  Rey- 
mond's  cases  (Fig.  216) 
shows  desquamated  epi- 
thelial cells,  sometimes 
without  their  nuclei, 
connective -tissue  cells, 
granular  fatty  degenera- 
tion, and  numerous 
streptococci.  The  mi- 
crobes are  sometimes 
strung  out  in  long 
chains,  while  in  other 
cases  they  appear  as  dip- 
lococci,  or  as  chains  of 
three  links,  each  one 
slightly  elongated. 

The  mucosa  is  gen- 
erally found  at  the  be- 
ginning of  the  affection 
to   have   undergone   but 

slight  modification.  The  epithelial  cells  are  yet  in  position  and 
have  retained  to  an  important  extent  their  cilia,  the  fimbrise  alone 
being  a  little  thickened  and  infiltrated  with  leucocytes.  In  re- 
cent infection  the  streptococci  are  found  in  the  calibre  of  the  tube, 
while,  according  to  Bumm,  the  streptococci  throng  about  the  epi- 
thelium of  the  pavilion,  although  they  do  not  infest  the  calibre  of 
the  tube  at  its  uterine  third.  It  is  inferred  from  this  that  the  micro- 
organisms must  have  travelled  over  some  other  highway  than  that  of 
the  lumen  of  the  tube  itself,  to  have  reached  the  vestibule.  At  a 
later  period  of  the  salpingitis,  if  the  lumen  remains  open,  the  mucosa 
shows  lesions  of  relatively  less  gravity  than  are  manifested  in  the 
other  tissues.  The  lymphatic  situated  in  the  centre  of  each  fimbria 
is  greatly  dilated,  and  contains  leucocytes  and  streptococci.     The  epi- 


FiG.  216. — "A  slide  mounted  with  pus  of  streptococcous 
salpingitis  from  one  of  Eeymond's  cases." — Keed. 


518 


A  TEXT-BOOK  OF   GYNECOLOGY 


thelimn  in  places,  while  almost  intact,  is  not  provided  with  vibratile 
cilia.  At  certain  points,  groups  of  streptococci  are  found  beneath 
superimposed  layers  of  epithelium,  which  is  occasionally  detached  en 
Hoc,  leaving  the  fimhrige  denuded.  The  tissues  underlying  this  de- 
nuded area  are  found  more  or  less  infiltrated  with  streptococci.  These 
changes  in  the  epithelium  explain  the  presence  of  the  detached  epithe- 
lial cells  in  the  pus.  It  is  noticed  that  in  streptococcous  infection  the 
superficial  cell  is  not  attacked  by  its  free  surface  as  in  gonorrhoeal  sal- 
pingitis, but  that  the  invasion  comes  from  the  deep  surface.  This  is 
an  essential  distinguishing  point  in  the  pathology  of  the  two  infections. 
As  a  result  of  this  assault  upon  the  epithelial  cells  from  their  base- 
ment membrane,  they  fall  in  masses,  and  not  singly  as  is  the  case  in 
the  presence  of  gonococcous  infection.  This  desquamation,  say  Eey- 
mond  and  Magill,  is  so  abundant  as  entirely  to  fill  the  calibre  of  the 
tube  with  the  detached  cells,  which  mass  together  and  can  clearly  be 
distinguished  from  the  fringes  in  a  section. 

The  changes  that  take  place  in  the  terminal  branches  of  the  blood 
vessels  are  difficult  to  determine,  and  it  is  even  more  difficult  to  de- 
termine the  relation  of  the  streptococci  to  the  blood  vessels.  The 
changes  are,  however,  found  most  frequently  at  the  periphery,  where 

are  sometimes  noticed 
thrombi  containing 
streptococci;  at  other 
times  the  endothelium  of 
the  vessels  is  seen  to  send 
out  23romontories  into 
their  lumen,  and  here 
are  found  streptococci 
both  within  and  without 
the  free  passage  of  the 
vessels.  These  changes 
are  all  grajDhically  shown 
in  a  section  of  a  fimbria 
in  streptococcous  salpin- 
gitis, by  Reymond  and 
Magill  (Fig.  217).  These 
observers  find  in  the  re- 
lation of  the  streptococci 
to  the  vessels  in  these 
cases,  confirmation  of  the 
conclusion  of  Labadie- 
Lagrave  to  the  effect  that  "  upon  the  blood  is  imposed  the  duty 
of  destroying  and  attenuating  the  streptococcus."  The  micro-organ- 
ism is  found,  particularly  at  the  beginning,  scattered  through  the 
cellular  tissue  of  the  aileron,  and  in  the  subperitoneal  tissue  also, 
as  the  adhesion  is  formed  with  the  tube  or  the  ovary.  An  abundant 
cellular  infiltration  is  formed  beneath  the  serosa,  whose  disappear- 


FiG.  217- — "  These  changes  are  all  graphically  shown 
in  a  section  of  limbriaj  from  a  case  of  streptococcous 
salpingitis,  by  Eeymond  and  Magill." — Eeed. 


INDIVIDUAL   INFECTIONS   OP   THE  FALLOPIAN  TUBES       519 

ance  leaves  a  point  still  marked  by  a  group  of  leucocytes  mixed  with 
streptococci,  which  are  also  found  in  the  cellular  infiltration  pro- 
duced between  the  muscular  sheaths. 

Tuberculosis  of  the  Fallopian  tubes  (Fig.  218)  is  the  most  frequent 
type  of  tuberculous  disease  of  the  female  genital  tract,  and  is  char- 


¥i(}.  218.— "  Tuberculosis  of  tlic  Fulloi.iiUi  tubes  is  the  most  frequent  type  of  tuberculous 
disease  of  the  female  genital  tract."— WniTAOUE. 


520  A   TEXT-BOOK  OP   GYNECOLOGY 

acterized  by  the  formation  of  miliary  tubercles  in  the  walls  of  the 
tube^  by  tumour  formation,  and  by  a  progressive  infection  of  the  re- 
mainder of  the  genital  organs. 

A  full  appreciation  of  the  frequency  and  clinical  importance  of 
the  condition  has  only  recently  been  obtained.  While  the  monograph 
of  Hegar  (1886)  did  much  to  bring  this  about,  that  of  Williams  (1892) 
gave  the  condition  a  rank  of  prime  importance,  by  demonstrating  a. 
very  much  greater  frequency  than  had  ever  before  been  imagined,  and 
by  showing  that  a  great  many  tubes,  previously  removed  as  adherent 
and  inflamed  appendages  or  passed  over  on  the  autopsy  table  without 
notice,  were  in  reality  tuberculous.  These  tubes  gave  no  macroscopic 
appearance  of  tuberculosis  and  were  called  by  him  cases  of  "  unsus- 
pected genital  tuberculosis."  This  possibility,  when  associated  with 
the  fact  that  excellent  results  are  obtained  by  the  removal  of  tubes  in 
a  condition  of  even  advanced  degeneration,  has  made  it  a  leading  sub- 
ject in  gynecology. 

The  method  of  infection  of  the  tube  by  the  tubercle  bacillus  forms 
an  important,  and  at  the  same  time  a  very  difficult,  question.  We 
distinguish  a  primary  and  a  secondary  infection  according  as  the  tuber- 
culous process  arises  primarily  in  the  tube  or  is  the  result  of  an  in- 
fection from  a  primary  focus  in  the  lung,  intestine,  or  peritoneum. 
The  latter  is  by  far  the  most  frequent  mode  of  infection. 

Hegar  has  differentiated  an  ascending  and  a  descending  form  of  in- 
fection, of  which  the  latter  is  always  a  secondary  tubal  tuberculosis, 
while  the  former  furnishes  all  the  primary  cases  and  ma}'-  be  a  second- 
ary tuberculosis.  In  the  ascending  type  of  infection,  the  tubercle 
bacillus  must  be  mechanically  deposited  in  the  vagina  or  uterus  by 
dirty  fingers  or  instruments,  from  the  clothes  or  the  fasces  of  the 
patient  who  suffers  from  tuberculous  enteritis,  by  coitus,  or  from  a 
tuberculous  ulceration  of  the  vulva  or  vagina.  It  is  conceded  that  the 
primary  form  of  infection  may  be  the  result  of  coitus  with  men  suffer- 
ing from  a  tuberculosis  of  one  or  more  of  their  genital  organs.  This 
belief  is  supported  by  these  facts:  (a)  That  tuberculosis  of  the  female 
genital  organs  occurs  with  greatest  frequency  between  twenty  and  forty 
years  of  age;  (b)  the  recognition  of  the  tubercle  bacilli  in  the  semen 
of  such  men  (Dewille);  (c)  the  demonstration  of  tubercle  bacilli  in 
the  apparently  sound  genital  organs  of  phthisical  men  (Fernet,  Jani); 
and,  finally,  (d)  the  demonstration  by  Schuchardt  of  tubercle  bacilli  in 
the  urethral  secretions  of  gonorrhoea. 

The  method  of  the  transfer  of  the  germs  from  the  vagina  to  the 
tube  without  infection  of  intermediate  organs  is  a  point  difficult  of 
solution.  The  escape  of  the  intermediate  tissues  (vagina,  cervix, 
uterus)  has  been  very  justly  compared  to  the  immunity  of  the  nose, 
throat,  and  larynx,  in  lung  tuberculosis  and  is  explained  by  their  natural 
protective  forces.  The  tube  lacks  protection  and  seems  to  offer  a  most 
suitable  nidus  for  bacterial  development.  The  spermatozoa,  by  reason 
of  their  peculiar  motion  upward,  would  seem  to  be  the  most  natural 


INDIVIDUAL   INFECTIONS  OF   THE   FALLOPIAN   TUBES       521 

carriers  of  adherent  infectious  material,  and  this  method  of  transfer 
is  accepted  by  Menge,  Pozzi,  Chiari,  and  Veit,  but  lacks  definite  proof. 
Hegar  believes  that  the  tubercle  bacillus  may  enter  by  slight  or  ex- 
tensive abrasions  of  the  mucous  membrane  of  the  vulva,  vagina,  or 
uterus,  travel  in  the  regular  course  of  the  lymphatic  stream,  and  find  a 
lodgment  in  the  outer  end  of  the  Fallopian  tube  or  the  ovary.  This 
belief  is  suj^ported  (1)  by  the  observations  of  Maier,  who  has  shown 
that  puerperal  inflammation  of  the  Fallopian  tubes  generally  begins 
at  the  outer  end;  (2)  by  the  fact  that  this  channel  of  transfer  has 
anatomical  support;  and  (3)  by  the  frequent  occurrence  of  tuberculous 
salpingitis  after  childbirth  and  abortion. 

The  descending  type  of  infection  is  more  easily  explained,  since 
Firmer  has  demonstrated  that  fine  bodies  (cinnabar  or  Chinese  ink) 
injected  into  the  peritoneal  cavity  will  soon  find  their  way  into  the 
tubal  ostium  through  the  tube  and  into  the  uterus.  Added  to  this, 
we  have  the  demonstration  that  the  tubercle  bacillus  and  other  bacteria 
may  pass  through  the  intestinal  wall  in  the  floor  of  a  tuberculous 
ulcer  and  float  free  in  the  peritoneal  cavity  (Mosler,  Jans).  The  ex- 
planation here  would  seem  to  be  complete.  The  tube  may  also  become 
diseased  through  direct  extension  in  continuity  of  tissue  from  a  neigh- 
bouring tuberculous  organ,  usually  from  the  peritoneum.  W.  Mayer 
has  collected  194  cases  of  secondary  tuberculosis  of  the  female  genital 
organs,  in  which  number  the  peritoneum  was  diseased  110  times;  in- 
deed, a  number  of  authors  have  considered  this  to  be  the  almost 
exclusive  method  of  tubal  infection.  A  secondary  disease  of  the  Fal- 
lopian tube  does  not  invariably  result  from  a  tuberculous  peritonitis, 
however,  as  will  be  shown  by  the  fact  that  Schramm  found  an  idio- 
pathic tuberculous  peritonitis  without  disease  of  the  tube  33  times 
in  3,356  autopsies.  Tuberculous  tumours  of  the  rectum,  sigmoid,  or 
mesenteric  glands,  may  also  communicate  the  infection  directly  to  an 
adherent  tube. 

An  infection  by  way  of  the  blood  stream  (hematogenous  infection) 
remains  to  be  mentioned,  and  there  is  no  reason  why  this  method 
should  not  be  given  the  importance  as  a  causative  factor  in  the  genital 
tract  that  is  attached  to  it  in  bone,  joint,  and  brain  tuberculosis.  The 
point  of  entrance  of  the  germs  may  show  no  tuberculous  changes  and 
the  only  lesion  in  the  entire  body  may  be  that  in  the  tube;  or  the 
primary  focus  in  the  lung  or  in  a  bone,  from  which  the  embolus  came, 
may  be  so  small  and  difficult  to  find  that  a  mistaken  diagnosis  of  a 
primary  disease  may  be  made  (Williams). 

Morhid  Anatomy. — The  lesions  of  tuberculous  salpingitis  are  usu- 
ally bilateral  although  present  in  a  different  degree  on  the  two  sides. 
The  general  appearance  of  the  organs  will  vary  greatly  with  the  stage, 
character,  and  severity  of  the  inflammatory  process.  The  type  desig- 
nated by  Williams  as  ''  unsuspected  tubal  tuberculosis  "  will  of  course 
not  be  observed,  and  the  more  advanced  cases  will  present  every  change 
fforn   sli'dii  r'nl;ir"'oirK'nt  to  the  most  extensive  mattinff  together  of 


522  ^  TEXT-BOOK  OF  GYNECOLOGY 

pelvic  contents  and  the  formation  of  abscesses.  The  tubes  that  we 
usually  see  have  already  undergone  a  more  or  less  high  degree  of 
change  and  their  form  does  not  vary  as  a  rule  in  any  way  from  that 
presented  by  ordinary  pus  tubeS;,  and  they  present  the  features  of  a 
well-developed  tuberculosis  (Fig.  219).  This  picture  of  tuberculosis 
is  formed  by  the  presence  of  typical  grayish-yellow  or  transparent  mili- 
ary nodules  on  the  surface;   the  lumen  is  dilated  and  filled  by  caseous 


Fig.  219. — "The  features  of  a  well  -  developed  tuberculosis":  A,  tube  wall  tliiekened ; 
£,  mucous  membrane  of  the  tube  in  a  condition  of  adenomatous  hyperplasia;  C,  broad 
ligament,  much  thickened;  Z>,  miliary  tubercles  on  the  peritoneal  surface  and  in  the 
mucosa;  E^  the  lumen  of  the  tube  sui-rounded  by  a  zone  of  caseous  degeneration. — 
Whitacre. 

material,  and  adhesions  bind  the  tube  down  in  the  pelvis.  The  ab- 
dominal end  may  be  open,  when  the  fimbriae  are  swollen  and  pushed 
over  the  opening;  or,  the  ostium  may  be  closed  by  a  plug  formed  of 
pseudomembrane  and  tubercle  tissue,  when  the  tube  may  become 
dilated  to  almost  any  degree  (Fig.  220),  and  may  assume  most  sur- 
prising shapes.  Veit  has  seen  a  case  in  which  the  isthmus  of  the  tube 
was  so  distended  as  to  give  the  appearance  of  an  extension  outward  of 


INDIVIDUAL  INFECTIONS   OP  THE   FALLOPIAN  TUBES       523 

the  uterine  cornu  (Fig.  221).     The  tube  contents,  according  to  their 
constituents,  may  be  fluid,  millcy,  of  the  consistence  of  cream  or  cheese. 


Fig.  220  (Veit). — "  The  tube  may  become  dilated  to  almost  any  degree." — Whitacee  (p.  522). 

or  at  times  chalky.     The  usual  type  is  a  grayish-yellow  cheesy  mass. 
The  mucous  membrane  also  shows  marked  changes  and  is  covered  by 


Fig.  221. — "  Veit  has  seen  a  case  in  which  the  isthmus  of  the  tube  was  so  distended  as  to  give 
tlic  appearance  of  an  extension  outward  of  the  uterine  cornu." — Whitaoke. 


524  A   TEXT-B(;OK   OF  GYNECOLOGY 

tubercles  in  every  stage  of  metamorphosis.  In  prolonged  cases  it  may 
be  entirely  replaced  by  a  necrotic  caseous  mass.  The  wall  of  the  tube  is 
usually  thickened. 

The  form  of  such  tumours  does  not  differ  from  that  of  tubes  other- 
wise inflamed.  Tumours  of  sausage^  retort,  and  torpedo  shape  are 
the  usual  forms,  while  Hegar  has  jDlaced  special  weight,  first,  on  a 
rosary-shaped  swelling,  and,  secondly,  on  a  swelling  at  the  isthmus  of  the 
tube  that  gives  the  aj)pearance  of  an  extension  outward  of  the  horn  of 
the  uterus.  A  closure  of  the  outer  end  may  result  in  a  dilatation  of 
the  tube  and  a  collection  of  pus  that  may  reach  two  quarts  (Stemann). 
The  tumour  will  be  further  modified  by  the  development  of  peritoneal 
products  and  adhesions.  The  position  of  the  tumour  shows  all  the 
variations  that  we  might  expect  in  severe  inflammatory  change.  Swi- 
talski  reports  a  case  in  which  a  tubal  tumour  the  thickness  of  a  finger 
was  found  in  front  of  the  uterus,  lying  on  top  of,  and  involving,  sec- 
ondarily, the  bladder  wall. 

According  to  the  manner  of  beginning,  the  lesions  may  be  divided 
into  an  acute  and  a  chronic  tubal  tuberculosis.  The  former  usually  fol- 
lows a  secondary,  and  the  latter  a  primary,  infection. 

The  acute  form  is  characterized  by  an  involvement  mainly  of  the 
ampulla,  and  a  rapid  breaking  down  of  the  tuberculous  mucous  mem- 
brane which  becomes  changed  into  a  cheesy  detritus.  Through  this 
process  the  muscle  is  destroyed  in  part  or  in  its  entirety,  and  the 
lumen  is  widened  to  a  certain  extent.  Microscopically,  the  mucous 
membrane  shows  a  rich  round-celled  infiltration  and  numerous  miliary 
tubercles  but  very  few  giant  cells,  owing  to  the  promptness  with  which 
a  central  necrosis  occurs  in  the  tubercles.  As  the  process  advances, 
the  mucous  membrane  becomes  changed  into  a  detritus  containing 
many  tubercle  bacilli.  The  muscle  layer  shows  distinct  miliary 
tubercles  between  the  fibres  or  caseous  areas. 

In  the  chronic  form,  the  abdominal  end  of  the  tube  becomes  promptly 
closed  and  a  pyosalpinx  forms.  The  destruction  of  the  mucous  mem- 
brane is  much  slower,  the  tube  may  be  very  much  dilated  by  pus 
formation,  and  the  thickening  of  the  muscular  wall  may  reach  such 
a  high  degree  that  the  tube  is  changed  into  a  hard,  stiff  formation. 
Microscopically,  this  form  begins  by  the  deposit  of  minute  miliary 
tubercles  in  the  mucous  membrane  beneath  the  epithelial  surface. 
These  tubercles  are  discrete,  typical  in  their  structure,  show  very  little 
tendency  to  caseate,  and  remain  confined  to  the  mucosa  for  a  long  time 
(Fig.  222).  This  stage  forms  the  type  of  "unsuspected  tubal  tuber- 
culosis," described  by  Williams,  and  will  be  revealed  only  on  micro- 
scopic examination.  An  increased  number  of  tubercles,  however,  will 
result  in  an  infiltration  and  swelling  of  the  folds  of  the  mucous  mem- 
brane, and  the  dilated  lumen  will  be  filled  by  what  seems  to  be  a  caseous 
tuberculous  mass  but  is  found  microscopically  not  to  have  broken  down 
in  any  part  (Martin).  At  other  times  the  tubercle  bacillus  excites 
decided  proliferation  in  the  glandular  elements  to  the  degree  of  dis- 


INDIVIDUAL   INFECTIONS  OF   THE   FALLOPIAN  TUBES       525 


Fig.  222. — "  These  tubercles  are  discrete,  typical  in  their 
structure,  .  .  .  and  remain  confined  to  the  mucosa 
for  a  long  time." — Whitacbe  (page  524). 


tinct  adenomatous  tumour  formations.  This  has  been  observed  with 
sufficient  frequency  to  call  for  special  mention  (Wolff,  Orthmann, 
Friedlancler,  Landau,  Eheinstein,  and  others),  and  is  considered  to  be  a 
hyperplasia  analogous  to 
that  of  the  epithelium 
in  lupus.  These  growths 
may  be  confused  with  ma- 
lignant tumours  and  it 
is  important  to  remember 
their  tuberculous  origin. 

The  tubercles  of  the 
chronic  type  have  many 
giant  cells  and  few  tuber- 
cle bacilli.  The  muscu- 
laris  does  not  become 
involved  until  very  late 
in  the  disease,  and  its 
marked  thickening  must 
be  looked  wpon  as  a  hy- 
pertrophy of  the  muscle 
and  connective-tissue  ele- 
ments, and  not  as  a  tuber- 
culous growth.  Tubercles 
may  be  found  in  the  mus- 

cularis  in  the  late  stages.  The  serosa  may  be  thickly  covered  by  hemp- 
seed-sized  tubercles  and  the  tubal  ostium  is  usually  closed  by  adhesions. 
A  true  pyosalpingitis  manifests  itself  in  relatively  few  cases  (Schroder, 
Winckel,  Martin,  Miinster). 

That  not  all  cases  permit  of  these  lines  of  division  into  an  acute 
and  a  chronic  form  is  certain,  but  in  general  it  will  serve  as  a  working 
basis.  Williams  has  made  a  division  into  three  forms:  a  miliary,  a 
chronic  diffuse,  and  a  chronic  fibroid  form.  His  miliary  form  corre- 
sponds to  the  early  stage  of  the  chronic  form  described  above;  while 
the  chronic  fibroid  form  is  described  as  one  characterized  by  a  rich 
formation  of  fibrous  tissue  in  and  around  the  miliary  tubercles,  and 
showing  almost  no  tendency  to  caseation. 

Both  the  closing  of  the  tubal  ostium  and  the  fibrous  thickenings 
found  in  the  chronic  forms  seem  to  be  a  curative  effort  on  the  part 
of  Nature.  Yet  it  must  be  remembered  that  the  caseous  contents  7naij 
escape  from  the  open  end  of  a  tube  into  the  free  abdominal  cavity 
(Hegar),  and  furthermore  that  encapsulation  does  not  always  occur 
when  this  does  take  place  (Knauer). 

Spontaneous  healing  may  also  certainly  take  place  by  a  calcification 
of  the  focus  (Kiwisch,  Rokitansky),  while  a  tuberculous  abscess  may 
heal  by  rupturing  into  the  rectum,  the  vermiform  appendix,  or  the 
.small  intestine  (Veit). 

The  gonococcus  has  boon  found  a  number  of  times  in  tuberculous 


526  A  TEXT-BOOK  OF  GYNECOLOGY 

tubes^  and  it  would  seem  probable  that  a  pre-existing  gonorrlioeal  sal- 
pingitis would  predispose  the  tube  to  a  tuberculous  infection. 

Symptoms. — The  symptoms  of  the  disease  are  in  general  those  of 
ordinary  salpingitis,  and  may  range  in  severity  from  entire  absence  in 
the  miliary  form  to  the  most  severe  symptoms  of  salpingitis  and  pelvic 
abscess.  Indeed,  the  symptoms,  subjective  and  objective,  are  so  little 
characteristic  that  the  abdomen  of  such  patients  is  usually  opened  for 
adherent  tubes  and  ovaries  or  for  pyosalpingitis.  Not  infrequently  a 
family  history  of  tuberculosis  or  the  discovery  of  tuberculosis  in  other 
parts  of  the  body  or  in  the  husband  (Menge),  serves  as  a  starting  point 
for  the  accurate  interpretation  of  the  symjDtoms.  In  cases  of  primary 
tuberculosis  of  the  tubes,  an  important  symptom  is  a  more  profuse 
and  painful  menstruation  (Martin),  while  amenorrhcea  is  of  course 
present  in  the  cases  of  coincident  phthisis.  The  pain  may  occur  on 
one  or  both  sides,  but  it  must  remain  a  question  as  to  how  much  of 
the  j)ain  depends  upon  the  tube  and  how  much  upon  the  peritoneum. 
The  temperature  is  not  elevated.  Ascites  may  be  present.  Symptoms 
may  persist  practically  unchanged  for  a  long  time,  as  has  been  shown 
by  "Werth,  who  reported  a  case  in  which  the  tuberculous  process  re- 
mained confined  to  the  tube  for  two  years  and  a  half. 

An  extension  of  the  process  to  the  peritoneum  gives  much  more 
characteristic  features  to  the  symptoms.  A  progressively  increasing 
pelvic  trouble,  chronic  in  its  nature  and  associated  with  tumour  forma- 
tion, the  matting  together  of  the  intestines,  disturbance  of  the  rectum, 
and  encj^sted  ascitic  fluid  extending  above  the  pubes,  generally  indi- 
cate tuberculosis.  A  secondary  infection  by  the  pyogenic  cocci  will 
of  course  initiate  the  more  acute  symptoms  of  sepsis.  Lastly,  a  primary 
tuberculosis  of  the  tube  may  lead  to  tuberculous  peritonitis,  phthisis, 
marasmus,  or  septic  peritonitis. 

Diagnosis. — From  what  has  been  said  of  the  symptomatology  it  is 
apparent  that  the  diagnosis  is  extremely  difficult;  indeed,  Gehle,  in 
1881,  stated  that  a  positive  diagnosis  of  genital  tuberculosis  could  not 
be  made.  This  statement,  of  course,  loses  all  authority  with  reference 
to  the  accessible  parts  of  the  genital  tract  since  the  discovery  of  the 
tubercle  bacillus,  but  it  still  holds  true  in  a  marked  degree  of  those 
cases  of  tubal  and  ovarian  disease  in  which  the  uterine  curettings  do 
not  contain  tubercle  bacilli. 

The  history  of  the  patient,  heredity,  and  the  existence  of  tuber- 
culosis in  other  organs,  are  important  points  in  the  diagnosis.  Hegar 
believes  that  a  rosary-formed  swelling  of  the  tube  occurs  more  fre- 
quently in  this  than  in  any  other  form  of  tubal  disease,  and  has  placed 
special  stress  upon  a  swelling  of  the  isthmus  of  the  tube  at  its  exit 
from  the  uterine  horn  (Martin).  Other  writers  believe  that  a  swelling 
in  the  outer  end  is  the  common  form  of  tumour  formation.  Attention 
has  also  been  called  by  many  observers  to  the  hardness  of  the  tumour, 
but  it  is  certainly  true  that  these  features  of  form  and  consistence  may 
be  present  likewise  in  pyosalpingitis. 


INDIVIDUAL  INFECTIONS  OF   THE  FALLOPIAN  TUBES       527 

If  the  tubes  are  not  too  firmly  bound  down,  the  diagnosis  may  be 
greatly  facilitated  by  feeling  tuberculous  nodules  on  the  surface  of 
the  tube,  on  the  pelvic  peritoneum,  or  on  the  posterior  surface  of  the 
uterus.  Edebohls  lays  great  stress  on  a  plaquelike  thickening  of  the 
peritoneum.  Osier  says  "  the  association  of  a  tubal  tumour  with  an 
ill-defined  anomalous  mass  in  the  abdominal  cavity  should  arouse  sus- 
picion at  once."  Tubercle  bacilli  may  be  found  in  the  secretions  of 
the  uterus  even  though  that  organ  be  uninvolved,  and  Edebohls  has 
once  aspirated  an  abscess  of  the  tube  and  discovered  tubercle  bacilli 
in  the  pus. 

Prognosis. — The  prognosis  is  always  grave  in  either  the  primary  or 
the  secondary  form.  In  the  former,  because  of  the  marked  tendency 
to  extend  to  the  peritoneum  or  lungs,  and  the  tendency  to  a  secondary 
pyogenic  infection  of  a  caseous  mass;  in  the  latter,  because  all  these 
symptoms  are  added  to  the  seriousness  of  the  primary  disease.  The 
brilliant  results  obtained  by  the  gynecologist,  even  in  advanced  cases, 
have  done  much  during  the  past  few  years  to  counteract  the  absolutely 
bad  prognosis  of  earlier  writers,  and  we  now  know  that  a  complete 
cure  of  the  condition  will  follow  excision  in  a  great  many  of  the 
primary  cases,  and  that  life  will  be  much  prolonged  in  the  advanced 
cases.    We  are  indebted  to  Hegar  for  this  radical  change  in  prognosis. 

Treatment. — The  prophylactic  treatment  of  tuberculous  salpingitis 
consists  in  cleanliness  on  the  part  of  the  physician  and  patient  and  in 
abstinence  from  marriage  and  coitus  by  people  siiffering  from  genital 
tuberculosis. 

By  reason  of  the  great  difficulties,  nay,  the  impossibility,  of  making 
a  diagnosis  in  many  cases  of  primary  tuberculosis,  we  are  not  often 
called  upon  to  decide  the  question  of  treatment.  Yet  when  the  disease 
is  discovered  during  an  operation  done  for  other  conditions  or  when  a 
diagnosis  is  made,  there  can  be  no  question  as  to  the  advisability  of 
radical  removal.  When  the  tubal  disease  is  associated  with  tuberculous 
peritonitis,  this  condition  gives  an  additional  reason  for  operation  rather 
than  a  contraindication.  In  patients  suffering  from  phthisis,  the  treat- 
ment of  a  secondary  tubal  disease  becomes  a  much  more  difficult  prob- 
lem. In  general,  the  condition  of  the  patient  must  be  carefully  con- 
sidered and  her  chances  of  life  weighed  with  and  withoiit  operation.  In 
other  words,  early  cases  should  be  operated  on,  late  cases  should  not. 

A  double  tuberculous  salpingitis  does  not  necessarily  call  for  hyster- 
ectomy, even  though  the  uterus  does  show  involvement  in  a  majority  of 
cases,  since  curetting,  combined  with  the  natural  resisting  power  of 
the  endometrium,  may  overcome  a  mild  infection. 

A  tonic  treatment,  pnre  air,  and  good  hygienic  surroundings,  have 
the  same  value  as  in  tuberculosis  of  other  parts  of  the  body. 

The  operative  treatment  of  these  cases  is  the  only  rational  one, 
and  the  excellent  results  reported  by  a  number  of  operators  will  justify 
excision,  even  in  those  cases  in  which  the  disease  has  extended  far 
beyond  the  appendages. 


528  A  TEXT-BOOK  OP   GYNECOLOGY 

Bacillus  Coli  Infection  of  the  Fallopian  Tubes. — The  Bacillus  coli 
communis  lias  been  found  to  be  the  essential  micro-organism  in  certain 
cases  of  tubal  infection.  Deaver  {Virginia  Medical  Semimonthly)  states 
that  there  is  frequently  a  close  relationship  between  acute  catarrhal 
appendicitis  and  right-sided  acute  salpingitis.  While  he  mentions  these 
as  separate  conditions,  calling  for  consideration  of  their  respective 
symptomatology  for  diagnostitial  purposes,  the  causal  relationship 
between  the  two  is  nevertheless  suggested.  The  role  of  the  Bacillus 
coli  communis  in  appendicitis  is  well  understood,  but  the  extension  of 
its  influence  to  the  Fallopian  tube  is  not  so  easily  comprehended  or  so 
generally  recognised.  Cases  of  salpingitis,  however,  in  which  the  bacil- 
lus coli  was  present,  have  been  reported  by  Morax,  Girode,  Hartmann, 
Doyen,  and  Keymond.  Individual  cases  have  also  been  reported  by 
Guyon,  Tuffier,  and  Schauta. 

The  causation  of  this  infection  may  be  summarized  under  the  head 
of  intestinal  adhesion.  The  intestinal  origin  of  this  infection  is  em- 
phasized by  Eeymond,  who  failed  to  find  it  in  a  single  case  in  which  the 
tube  was  not  adherent  to  the  intestine.  Actual  perforation  of  the 
intestine,  however,  does  not  seem  to  be  essential  to  enable  the  bacillus 
coli  to  migrate  from  its  native  habitat  to  the  lumen  of  the  Fallopian 
tubes;  on  the  contrary,  there  is  ample  evidence  that  the  infection  takes 
place  by  direct  passage  through  the  adhesions.  There  is  no  evidence, 
however,  to  justify  the  denial  of  a  possible  invasion  of  the  tubes  by 
progressive  infection  of  the  mucous  tract  through  the  vagina  and 
uterus.  The  fact  that  the  bacillus  coli  has  been  found  in  the  vagina 
indicates  the  possibility  of  a  general  infection  of  the  genital  tract  by 
that  route.  In  six  cases  studied  by  Eeymond  and  Magill,  the  condi- 
tions were  all  favourable  for  direct  infection  from  the  intestines.  In 
one  case  in  particular  the  right  tube  was  adherent  to  the  intestine 
and  contained  the  bacillus  coli,  while  the  left  tube,  which  was  not 
attached  to  the  intestine,  did  not  contain  that  micro-organism.  It 
would  seem  that  the  bacillus  coli  never  occurs  singly  as  an  infectious 
element  in  the  Fallopian  tubes;  on  the  contrary,  other  fine  bacteria 
appear  to  accompany  the  colon  bacillus,  but  they  have  not  been  classi- 
fied. These  bacteria  have  been  observed  by  Witte,  Morax,  and  Eey- 
mond and  Magill,  as  small  rods  much  more  slender  than  the  colon 
bacillus,  immovable,  colourable  by  Gram's  method,  and  of  variable 
length.  They  seem  to  add  to  the  offensiveness  of  the  pus  in  which  they 
are  found. 

The  symptoms  of  bacillus  coli  infection  of  the  Fallopian  tubes  are 
essentially  those  of  a  pyosalpinx.  In  view  of  the  fact  that  this  bacillus 
has  not  been  demonstrated  in  the  tube  in  the  absence  of  tubo-intestinal 
adhesions,  and  of  the  further  fact  that  such  adhesions  only  occur  as  the 
result  of  a  previous  infection  of  the  tube,  it  follows  that  the  history 
of  the  case  must  embrace  the  symptoms  of  the  preliminary  infection. 
This  may  be  gonococcous  infection  or  a  streptococcous  infection,  or 
it  may  be  a  so-called  mixed  infection,  by  which  is  implied  that  un- 


INDIVIDUAL   INFECTIONS  OP   THE   FALLOPIAN   TUBES       529 

differentiated  infection  which  is  probably  responsible  for  the  majority 
of  pus  tubes.  When,  however,  the  bacillus  coli  penetrates  the  Fallopian 
tubes,  the  symptoms  are  more  or  less  violent,  the  temperature  running 
very  high,  sometimes  to  105°  F.,  following  an  initial  chill.  The  rigors 
may  be  repeated,  followed  each  time  by  exacerbation  of  the  tempera- 
ture, with  increasing  evidences  of  systemic  intoxication,  verging  to  the 
fatal  point.  Spontaneous  relief  may  occur,  however,  by  the  abscess 
breaking  into  the  intestine  and  thus  draining  away. 

The  pathology  of  this  form  of  infection  does  not  differ  in  essential 
particulars  from  that  already  given,  (See  Morbid  Histology  of  Sal- 
pingitis.) The  bacilli  are  found  in  variable  quantity  in  the  pus;  some- 
times in  such  quantity  as  to  suggest  a  drop  of  culture  bouillon.  This, 
however,  is  exceptional,  as  in  other  cases  the  bacteria  are  so  rare 
that  microscopic  examination  of  the  pus  is  negative,  the  existence  of 
the  micro-organisms  being  revealed  only  by  cultures.  Leucocytes  are 
rare  in  the  pus,  while  the  epithelial  cells  are  more  numerous.  The 
manner  in  which  the  bacillus  coli  attacks  the  epithelium  does  not  seem 
to  be  settled.  If  it  is  granted  that  the  organism  finds  its  way  into  the 
tube  through  the  septum  formed  by  tubo-intestinal  adhesion,  it  follows, 
as  a  logical  result,  that  it  must  approach  the  epithelium  from  beneath; 
whereas,  if  the  method  of  invasion  is  through  the  uterus,  it,  like  the 
gonococcus,  attacks  the  epithelium  from  its  free  surface.  Eeymond 
and  Magill  record  the  significant  fact  that  in  all  sections  made  and 
coloured  by  them  with  NicoUe's  method,  they  were  never  able  to  find 
the  bacteria  elsewhere  than  in  the  salpingo-ovarian  pocket,  in  the 
midst  of  eliminated  cells,  and  at  the  surface  of  the  wall.  The  progres- 
sive accumulation  of  pus  is  more  rapid  than  in  the  ordinary  infections, 
and  results  in  extreme  distention  of  the  tube  which  may  rupture  either 
into  the  peritoneal  cavity,  or,  as  more  frequently  happens,  into  the 
intestine. 

Pneumococcous  Infection  of  the  Fallopian  Tubes. — The  infection  of 
the  Fallopian  tubes  by  the  pneumococcus  is  rare,  Eeymond  and  Magill 
never  having  observed  a  case,  although  one  each  has  been  reported 
by  Wertheim,  Zweifel,  and  Frommel.  It  would  seem  that  in  this  form 
of  infection  the  mischief  is  always  limited  to  the  tube  and  does  not  ex- 
tend to  the  ovaries.  The  majority  of  the  cases  are  unilateral,  the  pus 
being  small  in  quantity  and  the  tube  being  closed  at  its  pavilion.  The 
investigators  have  not  recorded  any  peculiar  appearances  in  the  micro- 
scopical sections  from  these  cases. 

The  symptoms  in  the  cases  on  record  are  those  of  an  acute  onset 
followed  by  high  temperature.  It  would  seem  either  that  the  pneumo- 
coccus is  of  varying  virulence,  or  that  the  patients  possess  different 
degrees  of  susceptibility,  since  the  escape  of  pus  into  the  peritoneum 
in  Zweifel's  case  caused  no  accident,  while  it  proved  rapidly  fatal  in 
the  cases  reported  by  Frommel  and  Witte. 

The  causation  of  this  form  of  infection  seems  to  be  shrouded  in 
mystery,  for  no  satisfactory  explanation  has  been  made  of  the  manner 


530  A  TEXT-BOOK  OP   GYNECOLOGY 

or  means  by  which  this  micro-organism  is  conveyed  from  its  natural 
habitat  to  the  Fallojaian  tubes.  In  none  of  the  cases  has  pneumonia 
been  present,  although  Stroganoff  has  observed  a  pelvic  abscess  that 
contained  capped  diplococci  in  several  cases  following  pneumonia.  It 
is  stated  that  in  cases  of  salpingitis  no  history  of  general  disease  which 
might  be  considered  the  primitive  cause  has  been  recorded.  An  exami- 
nation of  all  the  testimony  tends  to  render  untenable  an  hypothesis  of 
the  systemic  origin  of  the  infection.  The  probability  of  its  entrance 
through  the  genital  tract  seems  to  be  better  founded.  The  cases  of 
Witte  and  Frommel  show  that  the  infection  was  consecutive  to  puer- 
peral accidents;  while  gonorrhoea  was  the  antecedent  factor  in  the 
cases  of  Girode  and  Zweifel.  The  facts,  however,  that  the  pneumo- 
coccus  exists  normally  in  the  saliva,  and  that  among  certain  people  of 
depraved  habits  the  saliva  is  sometimes  used  as  a  lubricant  in  vaginal 
manipulations,  may  explain  its  presence  in  that  canal,  where  Doyen 
and  others  assert  that  they  have  found  it.  In  view  of  the  fact,  how- 
ever, that  its  normal  medium  is  alkaline,  it  is  hardly  to  be  assumed  that 
it  will  find  a  congenial  environment  in  the  presence  of  the  acid 
products  of  the  bacilhis  of  Doderlein.  The  assumption,  therefore,  that 
the  pneumococcus  is  to  be  classified  among  the  normal  bacteria  of  the 
vagina  seems  to  be  gratuitous. 

Staphylococcous  Infection  of  the  Fallopian  Tubes.— This  condition 
has  been  assumed  to  be  of  frequent  occurrence.  This  assumption, 
which  does  not  seem  to  be  well-founded,  is  manifestly  based  upon  the 
important  role  which  the  staphylococci  play  in  infections  in  general. 
These  micro-organisms  are  not  demonstrably  present  in  a  large  propor- 
tion of  salpingitides.  Schauta  found  them  but  4  times  in  144  examina- 
tions. Menge  found  them  once  in  26  cases,  Morax  once  in  33,  while 
Witte  found  them  but  tv/ice.  Boisleux  reports  that  he  has  observed 
them  several  times.  It  is  a  notable  fact  that  several  observers  who  have 
found  them  have  discovered  other  pathogenic  micro-organisms  present 
in  the  same  cases.  Eeymond  and  ]\Iagill  have  failed  to  find  them,  and, 
while  not  denying  the  accuracy  of  other  observations,  suggest  that  con- 
fusion may  have  arisen  from  the  fact  that  there  are  found  in  and  near 
the  Fallopian  tubes,  saprophytes  which  may  easily  be  confounded  with 
the  white  and  golden  staphylococcus.  The  microscopic  illusion  is 
heightened  by  the  fact  that  these  saprophytes  offer  the  same  appearance 
on  the  slide  and  show  cultural  properties  similar  to  the  staphylococci. 

Saprophytic  Infection  of  the  Fallopian  Tubes. — Witte  has  observed 
harmless  bacteria,  in  company  with  those  possessing  pathogenic  prop- 
erties, in  the  Fallopian  tubes,  but,  like  Eeymond,  has  not  come  to  a 
conclusion  as  to  their  proper  classification.  The  latter  notes  the 
significant  fact  that  they  resemble  the  species  which  normally  inhabit 
the  lower  portion  of  the  genital  tract,  but  is  not  prepared  to  believe 
that  they  are  indigenous  to  the  tubes.  The  conclusion  of  Sinclair,  that 
the  Fallopian  tubes  are  normally  free  from  bacteria,  is  in  accordance 
with  this  view.    (See  Bacteria  of  the  Fallopian  Tubes  in  Health.)    The 


INDIVIDUAL  INFECTIONS   OF  THE  FALLOPIAN  TUBES       531 

explanation  of  their  presence  in  the  tubes  rests  upon  purely  theoretic 
grounds.  The  fact  that  they  are  always  found  in  connection  with 
pathogenic  bacteria  suggests  that  they  migrate  thither  under  the  escort 
of  their  more  virulent  congeners.  They  do  not  penetrate  deeply  into 
the  mucosa  but  live  upon  its  surface.  In  those  cases  in  which  they 
seem  to  be  more  deeply  embedded,  it  is  found,  upon  careful  exami- 
nation, that  they  are  actually  within  an  epithelial  cul-de-sac  which  has 
become  more  or  less  displaced  by  the  inflammatory  thickening  of 
the  membrane.    They  are  not  discoverable  in  the  muscular  tunic. 

Septic  Vibrion  Infection  of  the  Fallopian  Tubes. — Infection  by  the 
vihrion  septique  of  Pasteur  {Bacillus  oedematis  maligni)  has  been  found 
in  the  I'allopian  tubes  by  Witte.  This  organism,  which  has  rounded 
edges,  and  varies  from  0.8  /*  to  1  /a  in  thickness  and  from  2  //.  to  10  /a  in 
length,  was  obtained  in  pure  cultures  by  Liborius.  It  produces  in  the 
lower  animals  a  hemorrhagic  oedema  in  the  subcutaneous  tissues  into 
which  it  is  injected.  The  infection  in  such  cases  is  limited  to  the 
immediate  area  of  injection  until  after  death,  when  it  becomes  rapidly 
diffused  throughout  the  system.  It  is  believed  to  be  the  cause  of 
emphysematous  gangrene  in  the  human  subject — although  the  role 
that  it  was  presumed  to  play  in  producing  gaseous  phlegmons,  is  now 
known  to  be  shared  by  the  Bacillus  aerogenes  capsulatus.  The  gaseous 
manifestations  were  present  in  Witte's  case  of  pyosalpinx.  It  has  also 
been  found  by  Giglio  in  company  with  the  Staphylococcus  pyogenes 
aureus  in  perimetric  abscess.  Its  method  of  invasion  of  the  Fallopian 
tubes,  and  the  exact  part  that  it  plays  in  general  pathology,  are  not 
accurately  understood. 

Actinomycosis  of  the  Fallopian  Tubes. — This  condition  has  been 
observed  by  Zemann,  the  lumen  of  the  tube  being  filled  with  pus  in 
which  the  parasite  abounded.  The  micro-organism  (Streptothrix  actino- 
myces)  attacked  the  walls  of  the  tubes,  which  were  thickened  and 
granular.     The  origin  of  the  infection  was  not  determined. 


CHAPTEE  XXXV 

TREATMENT   OF  INFECTIONS   OF   THE   FALLOPIAN   TUBES 

The  natural  course  and  termination  of  inflammatory  diseases  of  the  Fallopian 
tubes — Hygienic  treatment — Medicinal  treatment — Local  treatment — Massage 
— Electricity— Drainage :  Indications ;  varieties — Vaginal  incision  or  puncture 
— Inguinal  or  inguino-vaginal  incision  —  Abdominal  and  abdomino-vaginal 
incision — Rectal  puncture — Aspiration — Conservative  operations  on  the  tubes 
— Radical  treatment — Salpingectomy — Tait's  operation ;  modifications  of  Tait's 
operation — Abdominal  panhysterectomy — Doyen's  operation  (vaginal  hysterec- 
tomy) ;  modifications,  indications,  and  limitations. 

The  Natural  Course  and  Termination  of  Inflammatory  Diseases  of 
the  Tubes. — The  treatment  of  any  given  disease  should  be  based  upon 
the  knowledge  of  the  natural  history  of  that  disease.  The  application 
of  this  rule  to  the  treatment  of  infections  of  the  Fallopian  tubes,  in- 
volves primarily  a  consideration  of  the  natural  termination,  uninflu- 
enced by  operative  treatment,  of  the  inflammatory  diseases  induced  by 
the  infection.  This,  as  stated  by  Clark,  can  not  be  done  accurately  in 
our  present  state  of  knowledge,  for  the  reason  that,  during  the  last 
decade,  in  which  the  most  advanced  studies  in  gynecology  have  been 
made,  there  has  been  much  greater  activity  in  the  operative  field  than 
in  that  of  simple  palliative  treatment,  or  the  treatment  by  topical  appli- 
cations and  douches;  consequently,  no  series  of  cases  sufficiently  large 
to  offer  reliable  statistics  has  been  reported.  Notwithstanding  this 
deficiency  in  statistics,  general  observations,  as  recorded  by  many  gyne- 
cologists, point  very  strongly  to  the  possibility  of  a  restoration  ad  inte- 
grum in  many  cases  of  salpingitis  which  have  hitherto  been  subjected 
to  radical  operations.  In  considering  the  prognosis  in  the  acute  in- 
flammations of  the  tube,  two  principles  in  the  pathology  of  these  organs 
must  be  borne  in  mind.  First,  many  tubal  infections  are  self -limited; 
and,  secondly,  the  mucous  membrane  of  the  tube  is  extremely  difficult 
of  destruction.  With  a  decrease  therefore  in  the  virulence  or  cessation 
of  the  infection  in  the  simple  acute  inflammations,  the  second  factor 
becomes  active  and  tends  to  restore  the  tube  to  the  normal  condition. 
Whether  a  perfect  restoration  occurs,  depends  upon  the  extent  of  the 
injury.  While  we  accept  unhesitatingly  the  statement  that  the  ma- 
jority of  cases  of  simple  tubal  catarrh,  and  even  of  purulent  salpingitis, 
terminate  in  a  return  to  the  normal,  just  as  do  acute  catarrhal  and  sup- 
532 


TREATMENT  OP  INFECTIONS  OE  THE   FALLOPIAN  TUBES     533 

purative  processes  in  other  mucous  membranes,  nevertheless  when  a 
widespread,  round-celled  infiltration  of  the  muscular  layers  of  the 
tube  occurs,  with  a  subsequent  formation  of  new  connective  tissue, 
which  renders  the  tissues  dense,  nonvascular,  and  more  or  less  of  a 
low  vitalized  type,  an  anatomic  restoration  is  manifestly  impossible. 
From  the  purely  functional  standpoint,  however,  this  question  is  to  be 
considered  in  another  light.  Accepting  as  true  the  statement  that 
sterility  in  the  latter  class  of  cases  is  the  rule,  we  should  not  by  any 
means  unqualifiedly  infer  that  these  patients  will  become  chronic  in- 
valids, for  according  to  our  observation,  some  women  even  with  exten- 
sive adhesions  and  distortion  of  the  tubes  still  suffer  little  or  no  pelvic 
pain. 

With  the  conservative  spirit  which  now  prevails  among  gynecolo- 
gists in  regard  to  the  treatment  of  this  special  class  of  diseases,  we 
shall  no  doubt  find  with  the  accumulation  of  accurate  records  that  in 
simple  catarrhal  inflammations,  and  even  in  cases  of  undoubted  hydro- 
salpinx, a  self-limitation  of  the  disease  occurs,  especially  under  the 
influence  of  rest,  freedom  from  sexual  intercourse,  and  the  proper  ap- 
plication of  douches  and  other  remedies. 

The  ordinary  pyogenic  cocci,  such  as  the  streptococcus,  staphylo- 
coccus, colon  bacillus,  etc.,  appear  to  be  more  virulent  in  their  imme- 
diate action  than  the  gonococcus,  but  the  latter  is  much  more  persistent 
and  is  especially  prone  to  recur.  When  the  ordinary  pyogenic  cocci 
gain  access  to  the  tube,  their  cycle  of  activity  ends  with  the  acute 
attack,  after  which,  absorption  in  the  case  of  hydrosalpinx,  or  even  of 
pyosalpinx,  may  occur,  whereas  the  gonococcus  is  frequently  very  per- 
sistent and  is  self-perpetuating.  Once  infected  with  it,  the  pathological 
process  may  extend  over  months  and  years,  now  better,  now  worse,  de- 
pending upon  the  renewed  activity  of  the  gonococcus.  These  patients, 
therefore,  are  prone  to  become  chronic  invalids. 

There  is  little  danger  to  life  in  the  acute  or  recurrent  gonorrhoeal 
attacks  so  far  as  the  immediate  effect  is  concerned,  but  the  patient  may 
drag  out  a  miserable  existence,  suffering  more  or  less  pelvic  pain  for 
years.  So  far  as  the  ultimate  prognosis  is  concerned,  our  present 
knowledge  seems  to  indicate  a  more  permanent  recovery  in  those  cases 
which  survive  the  primary  infection  from  the  ordinary  pyogenic  organ- 
ism than  from  the  gonococcus,  at  least  so  far  as  a  restoration  of  the 
patient  to  a  condition  of  freedom  from  pain  and  discomfort  is  con- 
cerned. Hydrosalpinx,  while  often  very  painful,  is  not  dangerous,  and 
patients  tend  to  recover  without  operation,  the  fluid  being  absorbed 
just  as  in  similar  collections  in  other  cavities.  Wlien  aided  by  inci- 
sion and  puncture,  the  return  to  the  normal  is  greatly  facilitated. 

While  the  pus  of  a  pyosalpinx  may,  as  stated,  ultimately  be  ab- 
sorbed, this  appears  to  be  the  exception  rather  than  the  rule,  for  as  in 
other  collections  of  pus,  Nature  attempts  to  establish  an  exit;  at 
least  this  is  true  in  cases  in  which  the  pyosalpinx  reaches  a  consid- 
erable size. 


534  '         A  TEXT-BOOK  OF  GYNECOLOGY 

When  the  tube  is  small^  slow  gradual  inspissation  of  the  pus  may 
occur,  leaving,  in  its  later  stages,  only  a  granular,  cheesy  matter. 

In  some  of  these  cases,  small  calcareous  bodies,  which  ajjpear  to  be 
the  residual  debris  of  the  inspissated  pus,  are  also  found.  With  the 
progressive  accumvilation  of  pus  in  the  tubes,  the  coincident  perisal- 
pingitis results  in  firm  adhesions  to  the  surrounding  organs,  that 
prevent  the  ruj)ture  of  the  tube  into  the  abdominal  cavity.  Pelvic 
peritonitis  from  contiguity  of  organs  is  quite  common,  in  fact  is  almost 
an  invariable  rule,  but  widespread  general  peritonitis  is  quite  excep- 
tional as  a  result  of  purulent  contamination  through  the  rupture  of  the 
tube.  For  this  reason,  a  procrastinating  policy,  so  far  as  operation  is 
concerned,  should  usually  be  pursued  in  gonorrhoeal  salpingitis,  even  if 
pyosalpinx  is  formed;  for  it  is  better  to  wait  for  the  organisms  to  expend 
their  virulence  and  die,  rather  than  to  operate  in  the  acute  stage  when 
the  temperature  is  considerably  above  normal.  The  tube,  when  dis- 
tended with  pus,  frequently  drops  down  into  the  pelvis  posteriorly  to 
the  uterus,  and  often  in  cases  of  double  pyosalpinx  the  retort-shaped 
vestibular  ends  come  into  contact.  Following  the  rule  with  all  puru- 
lent collections,  the  pus  tends  to  rupture  in  the  direction  of  least 
resistance.  The  isthmiac  end  of  the  tube  being  either  occluded  or 
very  resistant,  offers  an  effectual  bar  to  the  escape  of  the  purulent  mat- 
ter into  the  uterus.  The  situation  of  the  bladder,  anterior  to  the  uterus, 
while  the  pyosalpinx  is  posterior,  renders  this  viscus  a  comparatively 
infrequent  channel  of  egress.  The  intestinal  canal,  therefore,  forms 
the  most  likely  cavity  into  which  the  abscess  will  tend  to  evacuate 
itself.  Because  of  the  dependent  position  of  the  tubes  in  Douglas's 
cul-de-sac  and  of  the  intimate  adhesion  of  the  upper  third  of  the 
rectum  and  the  lower  portion  of  the  sigmoid  flexure  to  them,  rupture 
usually  occurs  at  these  points,  although  the  small  intestine  may  prove 
Nature's  point  of  election.  AYhen  once  evacuated,  the  further  secretion 
of  pus  may  cease  and  obliteration  of  the  cavity  by  granulation  may  oc- 
cur; or,  on  the  other  hand,  reinfection  by  the  colon  bacillus  or  other  in- 
testinal organism  may  take  place  through  the  intestinal  opening,  and  a 
well-nigh  interminable  purulent  process  be  inaugurated.  Certainly, 
after  a  rupture  into  the  intestinal  canal  has  occurred,  a  reasonable  time 
should  be  given  for  the  closure  of  the  fistvilous  tract  before  an  operation 
is  resorted  to;  for  these  are  very  unfavourable  cases,  the  intestinal 
lesion  introducing  a  dangerous  factor  into  the  operative  treatment.  In 
some  cases,  the  pus  points  in  the  inguinal  region,  or  gravitates  down- 
ward under  Poupart's  ligament,  appearing  as  a  fluctuating  swelling 
in  the  femoral  canal. 

Clark  concludes  a  careful  study  of  the  natural  history  of  inflam- 
matory diseases  of  the  Fallopian  tvibes  with  the  statement  that,  while 
palliative  treatment  should,  hy  all  means,  he  employed  in  the  simpler  non- 
purulent inflammations  of  the  tuhe,  so  far  we  can  see  no  reason  to 
modify  the  surgical  rule  to  liherate  the  pus  hy  means  of  an  operation  rather 
than  to  ivait  for  its  natural  evacuation ;  for  Nature's  method  is  usually 


TREATMENT  OF  INFECTIONS  OF  THE  FALLOPIAN  TUBES     5^5 

"very  inferior  to  the  clean,  careful  work  of  a  good  surgeon.  If  left  alone, 
the  patient  is  subjected  to  many  months  of  very  serious  invalidism, 
whereas  proper  02:>erative  treatment  is  followed  by  much  more  certain 
and  radical  relief. 

Hygienic  Treatment. — While  the  prognosis  in  acute  salpingitis 
varies  according  to  the  etiology,  whether  simple,  gonorrhoeal,  or  sejatic, 
the  aim  of  the  medical  treatment  in  each  variety  is  practically  the 
same.  We  can  not  expect  to  arrest  the  process  after  it  has  once  ex- 
tended to  the  tube,  but  we  can  assist  Nature's  method  of  cure,  which 
consists  in  the  absorption  of  inflammatory  products,  the  occlusion  of 
the  distal  end,  or  the  adhesion  of  the  diseased  tube  to  adjacent  organs 
so  that  infectious  fluids  are  shut  oif  from  the  general  cavity.  Abso- 
lute rest  in  the  recumbent  position  must  be  insisted  upon,  the  patient 
not  being  allowed  to  leave  her  bed  for  any  purpose.  Sexual  excitement 
is  especially  to  be  avoided — the  husband  being  strictly  cautioned  as 
to  this  point.  If  the  menstrual  flow  appears  during  the  acute  attack, 
these  precautions  are  still  more  necessary.  The  regulation  of  the 
bowels  is  of  primary  importance,  as  thorough  purgation  often  cuts 
short  an  attack,  or  at  least  limits  the  inflammatory  process.  Half- 
grain  tablets  of  calomel,  one  every  half  hour,  followed  by  teaspoonful 
doses  of  siilphate  of  magnesium  or  phosphate  of  sodium,  are  usually 
followed  by  several  loose  movements.  If  the  stomach  is  irritable,  six 
or  eight  ounces  of  a  saturated  solution  of  salts,  may  be  introduced  into 
the  bowel  through  a  long  rectal  tube.  After  the  bowels  have  been 
opened,  the  saline  laxative  should  be  repeated  daily.  If  the  tempera- 
ture is  elevated  above  101°  F.,  an  ice  bag  or  cold-water  coil,  applied 
over  the  lower  abdomen,  not  only  relieves  pain,  but  often  controls  the 
accompanying  peritonitis.  Some  patients  can  not  tolerate  cold,  but 
find  more  relief  from  hot  stupes  or  poultices.  Hot  vaginal  douches 
(110°  to  115°  F.)  are  exceedingly  useful  in  the  acute  stage,  but  they 
should  be  given  every  six  hours,  not  less  than  a  gallon  of  water  being 
used  each  time.  High  enemata  of  saline  solution  not  only  relieve  tym- 
panites, but  stimulate  the  renal  functions.  Pain  is  best  relieved  by 
codeine  supiDositories,  hypodermatic  injections  of  morphine  being  given 
only  when  absolutely  necessary.  Strychnine  is  a  more  reliable  stimu- 
lant than  alcohol. 

In  short,  the  treatment  of  a  case  of  acute  saliaingitis  is  identical  with 
that  of  localized  peritonitis,  with  the  details  of  which  the  reader  is  suf- 
ficiently familiar.  If  adopted  promptly  and  carried  out  thoroughly,  most 
nonseptic  cases  will  either  go  on  to  resolution  with  more  or  less  restora- 
tion of  function,  or  the  patient  will  recover  with  thickened  and  adherent 
tubes,  to  become  the  subject  of  future  medical  or  surgical  attention. 
In  the  nonsurgical  treatment  of  chronic  salpingitis  the  physician  seeks 
to  relieve  pain  and  disability,  to  promote  the  absorption  of  exudates  and 
the  stn.'tcliing  of  adhesions  around  an  imprisoned  tube,  and  to  restore 
its  physiologic  functions  so  lliat  conception  may  become  a  possibility. 
WhJI<;  considerable  confidence  may  be  felt  in  reparative  natural  pro- 


536  A  TEXT-BOOK  OP   GYNECOLOGY 

cesses,  since  the  physician  can  not  know  the  exact  anatomic  condition 
without  opening  the  abdomen,  he  should  be  careful  about  promising- 
a  complete  cure  or  entire  freedom  from  subsequent  attacks  under  con- 
ditions favouring  fresh  traumatisms  or  infection.  It  is  assumed  that 
the  cases  under  consideration  are  those  in  which  the  tube  is  merely 
thickened  and  adherent,  especially  in  Douglas's  pouch,  with  or  with- 
out accompanying  disease  of  the  ovary.  A  patient  with  this  condition 
must  be  taught  to  take  the  best  care  of  herself.  She  should,  while  tak- 
ing daily  exercise  in  the  open  air,  be  constantly  on  her  guard  against 
over-exertion,  indulgence  in  violent  sports  (golf,  bicycling,  or  bowling), 
exposure  to  cold,  in  fact,  anything  which  might  light  up  a  fresh  attack 
of  inflammation.  If  sexual  intercourse  can  not  be  interdicted,  it  should 
occur  at  infrequent  intervals,  with  due  cautions  against  violence  or 
excess.  Unless  the  cheerful  co-operation  of  the  husband  can  be  se- 
cured, all  treatment  will  be  unsatisfactory.  Eest  during  menstruation 
is  a  desideratum,  at  least  during  the  first  two  or  three  days.  Patients 
must  be  taught  that  this  is  the  period  when  they  are  most  liable 
to  recurrent  attacks.  The  deleterious  influence  of  pregnancy  and 
abortion  upon  old  tubal  troubles  is  well  known,  so  that  it  is  quite 
within  the  province  of  the  physician  to  caution  against  the  risks 
attending  conception  in  subacute  cases,  especially  those  of  gonor- 
rhoea! origin. 

Medicinal  Treatment. — Various  drugs  have  been  mentioned  as  hav- 
ing almost  specific  action  upon  tubal  disease,  such  as  bichloride  of 
mercury,  chlorate  of  potassium,  and  the  iodides;  but  this  action,  when 
apparently  beneficial,  must  be  due  rather  to  the  improvement  effected 
in  the  general  health,  especially  in  syphilitic  subjects.  Tonics  and  laxa- 
tives are  always  indicated.  Careful  regulation  of  the  bowels  by  cas- 
cara,  podophyllin,  or  salines,  with  occasional  high  enemata,  should  be 
a  routine  measure.  Warburg's  tincture,  iron,  and  strychnine,  are  never 
amiss.  For  the  correction  of  gastric  disturbances  and  excess  of  uric 
acid,  teaspoonful  doses  of  phosphate  of  sodium  in  hot  water  act  most 
satisfactorily;  indeed,  when  this  simple  remedy  is  used  habitually  it  is 
usually  unnecessary  to  give  any  other  laxative.  The  action  of  the  kid- 
neys should  be  stimulated  by  the  daily  ingestion  of  large  quantities  of 
pure  water.  Alcoholic  stimulants  are  to  be  avoided,  unless  strongly 
indicated  on  account  of  the  weak  condition  of  the  patient,  especially 
during  menstruation  when  they  are  apt  to  be  used  in  excess  to  relieve 
pain.  The  temptation  to  resort  to  morphine  to  relieve  dysmenorrhoea 
is  strong,  but  should  be  resisted  as  far  as  possible.  If  opium  must  be 
used,  codeine,  in  the  form  of  suppositories,  is  preferable,  or  the  coal- 
tar  derivatives  may  be  employed  without  overlooking  their  depressing 
effect  on  certain  subjects.  Counter-irritation  over  the  abdomen  with 
blisters,  leeches,  or  the  thermo-cautery,  often  aft'ords  temporary  relief 
to  local  pain,  but  no  actual  effect  upon  the  pathologic  condition  within 
the  pelvis  is  to  be  expected.  The  same  comment  applies  to  painting 
the  vaginal  fornix  with  tincture  of  iodine.    In  scanty  menstruation,  iron 


TREATMENT  OP  INFECTIONS   OP  THE  PALLOPIAN  TUBES     537 

and  manganese  are  indicated.  Menorrhagia  is  treated  with  small  doses 
of  strychnine,  ergot,  and  hydrastin,  or  stypticin  in  2-grain  doses 
every  four  to  six  hours  until  the  profuse  flow  is  checked.  Since  in  these 
cases  the  endometrium  is  in  a  state  of  hyperplasia,  curettement  is 
usually  the  most  direct  method  of  relieving  the  symptom.  It  is  hardly 
necessary  to  add  that  the  hot  vaginal  douche  is  indispensable  in  the 
treatment  of  chronic,  as  well  as  of  acute,  salpingitis. 

Local  Treatment. — In  the  medicated  tampon  we  have  probably  the 
best  local  agent  for  the  treatment  of  diseased  and  adherent  tubes.  In 
many  cases  it  certainly  relieves  pain  and  assists  in  the  absorption  of 
exudates,  as  proved  by  the  marked  diminution  in  the  size  and  sensi- 


FiG.  223. — "  Aside  from  the  advantage  gained  by  supporting  enlarged  and  displaced  tubes, 
the  habitual  use  of  the  tampon  seems  to  improve  the  pelvic  circulation."— Coe. 


tiveness  of  the  pelvic  tumour.  That  a  restitutio  ad  integrum  can  be 
thus  obtained,  only  an  ultra-enthusiast  would  assert.  Yet  the  per- 
sistent use  of  the  tamponade  has  relieved  many  women  from  a  state 
of  invalidism  when  an  operation  seemed  inevitable,  so  that  they  be- 
came practically  well  and  were  able  to  conceive  and  bear  children. 

Glycerine,  boro-glyceride,  and  iehthyol,  are  the  medicaments 
usually  employed — the  two  latter  in  a  10-per-cent  solution  in  glycerine. 
Aside  from  the  advantage  gained  by  supporting  enlarged  and  displaced 
tubes  (Fig.  223)  (especially  when  the  uterus  is  retroflexed),  the  habitual 
use  of  the  tampon  seems  to  improve  the  pelvic  circulation,  while  the 
ichthyol-glycerine  seems  to  have  almost  a  specific  action  upon  firm  exu- 
dates, which  soften  and  melt  away  under  its  influence.  In  order  to  ac- 
complish decided  results  the  tampon  should  be  inserted  at  least  two  or 
three  times  weekly.    The  patient  being  in  the  knee-chest  position  and 


538  A  TEXT-BOOK  OP  GYNECOLOGY 

the  vaginal  fornix  exposed  with  a  Sims's  speculum,  two  pledgets  of  ab- 
sorbent cotton  saturated  with  the  ichthyol  solution,  are  pushed  up 
firmly  against  the  tumour  and  a  dry  tampon  is  applied  on  them.  As 
the  patient  becomes  more  tolerant  greater  pressure  can  be  exerted,  the 
number  of  tampons  being  increased  with  the  view  of  stretching  adhe- 
sions and  lifting  the  mass  out  of  the  pelvis.  The  patient  is  instructed  to 
leave  them  in  situ  for  thirty-six  or  forty-eight  hours,  meanwhile  wear- 
ing a  napkin  on  account  of  the  discharge  which  always  occurs.  After 
they  are  removed,  hot  douches  are  used  until  the  next  treatment. 

While  patients  learn  to  introduce  the  tampons  themselves,  it  is  a 
question  if  they  ever  push  them  beyond  the  cervix.  To  meet  this  objec- 
tion King  has  devised  a  tube  for  injecting  the  solution  into  the  pos- 
terior fornix,  a  dry  pledget  being  afterward  inserted  to  retain  it  in 
the  vagina.  In  23i'actice  it  has  been  found  that,  in  order  to  accom- 
plish the  desired  result,  the  tamjjon  must  be  carefully  introduced  by 
the  physician  in  the  way  described.  It  is  impossible  to  do  this  prop- 
erly through  a  bivalve  speculum. 

Massage. — So  much  has  been  written  about  pelvic  massage  that  it 
is  impossible  to  do  more  than  touch  ujjon  it  here.  While  Coe  does  not 
disparage  this  method  of  treatment,  which  has  given  such  excellent  re- 
sults, he  is  not  enthusiastic  with  regard  to  its  application  to  the  separa- 
tion of  intrapelvic  adhesions.  The  unexpected  extent  and  firmness  of 
those  often  found  on  opening  the  abdomen,  and  the  difficulty  of  sepa- 
rating them,  even  under  the  direct  guidance  of  the  eye,  leads  one 
to  infer  that  the  relief  experienced  from  the  massage  of  adherent  tubes 
and  ovaries,  is  due  rather  to  improvement  of  the  pelvic  circulation  and 
the  general  conditions  of  the  patient,  than  to  the  actual  absorption  of 
exudates  and  the  breaking  up  of  bands  of  organized  lymph.  A^^iile  an 
expert  might  venture  in  carefully  selected  cases  to  attempt  the  evacua- 
tion of  pus  and  other  fluids  by  "  stripping  "  a  distended  tube  into  the 
uterus,  the  practitioner  will  do  well  to  confine  his  manipulations  to 
cases  of  thickened  and  adherent  tubes  in  which  there  is  no  evidence 
of  subacute  inflammation,  and  where  the  first  careful  attempt  is  not 
followed  by  unpleasant  reaction.  The  technique  is  briefly  as  follows: 
The  patient  lies  upon  a  Ioav  couch,  with  her  clothing  thoroughly  loos- 
ened, the  knees  flexed,  and  the  hips  raised  on  a  cushion.  The  operator, 
sitting  on  a  low  chair  at  one  side,  introduces  one  or  two  fingers  into 
the  vagina  and  exerts  steady  gentle  pressure  against  the  mass,  while 
his  other  hand  makes  counter-pressure  over  the  abdomen.  Some  re- 
sistance may  be  experienced  at  first,  but  with  patience  the  tension  of 
the  muscles  will  be  overcome,  so  that  the  opposing  fingers  may  be 
approximated,  grasping  the  mass  between  them.  Light  kneading  with 
the  abdominal  hand  enables  him  to  put  the  adhesions  on  the  stretch. 
The  rule  in  pelvic  massage  is,  not  to  begin  with  the  exudate,  but  to 
direct  the  strokes  upward  and  outward,  with  the  view  of  emptying  the 
pelvic  veins.  The  first  seance  should  be  tentative,  not  being  prolonged 
beyond  five  or  ten  minutes.    If  marked  pain  is  experienced  during  the 


TREATMENT  OF  INFECTIONS  OF  THE  FALLOPIAN  TUBES     539 

treatment,  or  pain  and  infiammatory  reaction  afterward,  it  is  more  than 
doubtful  if  it  will  prove  beneficial.  Should  the  first  treatment  be 
satisfactory,  it  may  be  repeated  two  or  three  times  weekly  for  ten 
or  fifteen  minutes  at  a  time.  It  is  wise  to  suspend  treatment  just 
before  and  after  the  menstrual  period.  In  order  to  save  what  has  been 
gained  in  the  way  of  stretching  adhesions,  it  is  well  to  introduce  as 
firm  a  tampon  as  the  patient  can  bear.  In  a  favourable  case,  j)er- 
sistent  massage  will  restore  a  considerable  range  of  mobility  to  the 
adherent  uterus  and  adnexa,  so  that  it  may  even  be  possible  for  the 
patient  to  wear  a  soft  rubber  pessary  with  comfort.  Circumscribed 
exudates  are  softened  and  absorbed  and  become  insensitive,  menstrua- 
tion becomes  regular  and  less  painful,  and  the  patient's  general  health 
is  sensibly  improved.  It  need  not  be  added  that  pelvic  massage,  as 
thus  outlined,  is  not  to  be  confounded  with  the  forcible  separation 
of  adhesions  under  aneesthesia,  an  operation  which  calls  for  special 
tactile  dexterity  and  is  not  free  from  risk. 

Electricity. — The  extravagant  claims  of  former  electro-therapeu- 
tists are  no  longer  regarded  seriously.  It  is  admitted  that  one  need 
not  look  for  any  mysterious  action  of  electricity  upon  diseased  organs, 
whereby  an  anatomical  cure  may  be  obtained.  It  is  simply  an  adjuvant 
in  the  treatment  of  pelvic  diseases,  serving  to  relieve  pain  and  to 
stimulate  the  pelvic  circulation.  While,  for  the  scientific  apj^lication 
of  this  agent,  elaborate  and  expensive  apparatus  is  necessary,  for  ordi- 
nary office  practice  a  good  galvanic  battery  (preferably  the  dry-cell 
variety)  is  suliicient  for  gynecological  treatment.  A  milliamperemeter, 
while  usefiil,  is  not  indispensable,  since  the  patient's  sensations  and 
the  after-efi^ect  of  the  treatment  are  the  best  guides  in  its  apj^lication. 
Local  pain  is  tlie  indication  for  electricity.  As  in  the  case  of  mas- 
sage, the  contraindications  are  subacute  inflammation  and  the  pres- 
ence of  a  suspected  pus  focus  in  or  around  the  tube.  A  ball  electrode, 
covered  with  wet  clay,  chamois,  or  absorbent  cotton,  and  connected 
with  the  negative  terminal,  is  introduced  into  the  vagina  and  pressed 
against  the  sensitive  mass,  while  the  positive  electrode  (clay  or  wire 
gauze  covered  with  cloth)  is  placed  over  the  lower  part  of  the  abdomen. 
Beginning  with  a  weak  current,  this  is  gradually  increased  up  to 
30  milliamperes,  or  until  the  patient  feels  a  distinct  warmth  or  burn- 
ing sensation,  but  no  pain.  Women  differ  greatly  as  to  the  degree 
of  tolerance,  but  it  is  not  well  to  exceed  50  milliamperes.  The  seance 
lasts  from  five  to  fifteen  minutes  and  may  be  repeated  two  or  three  times 
a  Aveek.  The  patient  should  experience  subsequently  a  general  feeling 
of  well-being,  with  relief  of  the  local  pain.  If  it  is  found  after  two 
or  three  applications  that  the  pain  is  increased,  or  if  there  is  any  other 
unpleasant  reaction  (rise  of  temperature,  etc.),  it  is  wiser  not  to  persist 
with  it.  Intrauterine  galvanization  with  the  positive  pole  may  be 
practised  when  monorrhagia  is  a  marked  symptom,  but  this  is  not 
generally  recommended  in  connection  with  pelvic  exudates.  An 
equally  good  sedative  efrect  is  obtained  by  using  the  fine  wire  faradic 


540  A   TEXT-BOOK   OF   GYNECOLOGY 

current  with  a  bipolar  vaginal  electrode,  and  there  is  seldom  any  re- 
action. The  patient's  sensations  form  the  best  indications  as  to  the 
strength  of  the  current. 

In  touching  briefly  upon  the  nonsurgical  treatment  of  salpingitis, 
Coe  would  emphasize  (1)  the  fact  of  its  limitations;  (3)  the  necessity 
for  accurate  diagnosis  and  care  in  the  selection  of  cases;  and  (3)  that 
an  anatomical  cure  is  not  to  he  expected.  It  is  the  aim  of  the  physician, 
with  the  intelligent  co-operation  of  the  patient,  to  relieve  symptoms 
and  to  preserve  organs  which,  though  diseased,  are  not  a  menace  to 
life,  and  may  under  judicious  treatment  be  restored  to  functional  use- 
fulness, if  not  to  a  normal  condition.  Operative  intervention  may 
in  the  end  be  necessary,  but  the  patient's  wish  to  make  a  fair  trial  of 
less  radical  methods  should  be  regarded,  and  the  results,  even  in  cases 
which  at  first  appear  to  be  purely  surgical,  are  often  so  good  that  an 
operation  is  avoided.  If  it  is  eventually  performed,  the  patient's  local 
and  general  condition  have  been  so  much  improved  by  the  preparatory 
treatment  that  the  operation  is  rendered  much  easier  and  safer,  and 
more  satisfactory  in  its  ultimate  results. 

Treatment  by  Drainage. — In  certain  cases  of  purulent  accumula- 
tions, not  only  within  the  Fallopian  tubes,  but  in  the  lymphatics  and 
in  the  ovaries,  the  condition  of  the  patient  is  such  that  a  judicious 
operator  may  deem  it  advisable  to  improve  her  condition  before 
attempting  the  radical  operation.  The  initial  step  in  such  a  course 
of  treatment  must  be  the  removal  of  the  pus. 

The  indications  and  limitations  of  drainage  as  a  means  of  treatment 
in  pelvic  disease  should  be  distinctly  recognised.  It  may  be  said  to  be 
indicated  in  all  cases  in  which  there  is  manifestly  an  extensive  accumu- 
lation of  pus,  and  in  which  the  active  constitutional  symptoms  indi- 
cate that  the  causative  pathogenic  micro-organisms  are  not  only  yet 
alive,  but  virulent.  In  such  cases,  to  attempt  the  removal  of  the  Fal- 
lopian tube,  for  example,  by  abdominal  section,  would  simply  mean  to 
expose  the  patient  to  an  unnecessary  hazard  through  the  liability  of 
rupturing  the  tube  and  consequently  of  contaminating  the  peritoneum. 
In  all  such  cases  it  is  better  to  evacuate  the  pus  by  some  sort  of  punc- 
ture than,  under  the  circumstances,  to  attempt  the  ablation  of  the 
appendages  by  either  vaginal  or  abdominal  incision.  While  this  is 
true,  it  is  nevertheless  important  to  recognise  that  the  treatment  is 
essentially  tentative;  in  other  words,  that  it  is  a  means  of  affording  the 
patient  only  temporary  relief,  and  of  placing  her  in  a  reasonably  safe 
condition  for  the  more  radical  operation  which,  in  the  majority  of 
cases,  should  follow.  This  is  the  only  representation  that  the  operator 
is  justified  in  making  to  his  patient.  In  numerous  cases,  however, 
symptomatic  cures  have  followed  drainage,  but  this  result  is  never  to 
be  counted  upon.  It  may  be  stated,  as  a  rule,  therefore,  that  pelvic 
drainage  as  an  elective  operation  should  only  be  employed  as  a  tem- 
porary expedient,  by  which  the  patient  may  be  put  into  a  proper 
general  condition  for  a  radical  operation. 


TREATMENT  OF  INFECTIONS  OF  THE  FALLOPIAN  TUBES    54I 


The  varieties  of  drainage,  or,  in  other  words,  the  various  avenues  and 
instrumentalities  by  which  drainage  may  be  effected  in  these  cases, 
may  be  summarized  as  follows:  (a)  vaginal  puncture;  (6)  inguinal  and 
inguino-vaginal  incision;  (c)  abdominal  or  abdomino-vaginal  incision; 
(d)  rectal  puncture;  (e)  aspiration.  Drainage  when  once  established 
may  be  maintained  by  a  tube,  by 
gauze,  or  by  open  incision. 

The  vaginal  incision,  in  certain 
cases  more  properly  called  vaginal 
puncture,  is  the  method  of  election 
in  the  majority  of  cases. 

The  cases  which  are  best  adapted 
to  this  method  of  drainage  are  those 
in  which  the  purulent  accumulation 
lies  behind  the  uterus  in  the  cul-de- 
sac,  or  behind  the  posterior  folds  of 
the  broad  ligament  upon  either  side, 
or  in  which  the  suppuration  has  oc- 
curred primarily  in  the  lymphatics 
of  the  pelvis  and  has  burrowed 
thence  posteriorly  or  laterally  round 
the  uterus  and  the  upper  portion  of 
the  vagina.  In  such  cases,  the  prod- 
ucts of  sujDpuration  can  be  most 
easily  removed  through  the  vagina. 
The  operation  is  done  in  various 
ways.  The  patient  should  in  all  in- 
stances be  carefully  prepared.  Some 
operators  prefer  to  place  the  patient 
in  a  recumbent  posture,  with  her 
knees  flexed  well  upon  her  thorax, 
the  extreme  Simon  position,  and,  in- 
serting a  perineal  retractor,  to  locate 
the  most  dependent  portion  of  the 
purulent  sac  or  cavity,  which  is  then 
opened  with  a  bistoury.  This  is  far 
from  being  a  safe  method  of  pro- 
cedure, for  the  reason  that  in  prac- 
tically all  these  cases  there  is  more 
or  less  distortion  of  the  tissues  and 
consequent     displacement     of     the 

blood  vessels.  A  free  incision,  therefore,  in  a  locality  which,  under 
normal  condition.s,  will  be  entirely  safe,  may  result,  in  these  cases, 
in  the  division  of  the  blood  vessels  and  a  consequent  serious  and  often 
fatal  hemorrhage.  It  is  better,  therefore,  to  adopt  the  method  de- 
scribed many  years  ago  by  Clinton  Gushing  and  to  make  this  opening 
by  means  of  a  dilating  plunger. 


Fig.  224. — "Keed  uses  a  sharp-pointed 
curved  dilator"  (page  542). 


542 


A  TEXT-BOOK  OF   GYNECOLOGY 


This  consists  in  a  pair  of  sharp-pointed  dilators  which  are  easily 
inserted^  and,  when  opened,  simply  tear  an  orifice  large  enough  to  per- 
mit free  drainage.  Eeed  nses  a  sharp-pointed  curved  dilator  (Fig.  224) 
and  prefers  to  have  the  patient  in  a  recumbent  posture  with  her  knees 
but  moderately  flexed,  to  have  no  perineal  retractor,  but  to  use 
his  finger,  exclusively,  as  a  guide  for  directing  the  instrument,  which 
can  thus  be  inserted  with  greater  accuracy  in  any  direction  (Fig.  225). 


Fig.  225. — "Keed  prefers  to  use  liis  tiuger,  exclusively,  as  a  guide  for  directing  the  instrument." 


The  index  finger  should  be  inserted  into  the  orifice  thus  formed, 
no  hesitancy  being  experienced  in  exei'cising  the  necessary  force  to 
accomplish  this  end.  A  free  exploration  of  the  cavity  is  thus  made, 
the  abscess  sac  is  washed  out,  first  with  a  clear  sterilized  saline  solu- 
tion, and  afterward  with  pure  peroxide.  Eeed  has  latterly  thrown  in 
freely  a  solution  of  95-per-cent  carbolic  acid,  rinsing  the  part  imme- 
diately with  pure  alcohol,  and  has  found  it  the  most  effective  anti- 
septic procedure  that  he  has  ever  employed.  After  this,  the  cavity  may 
be  packed  with  sterilized  bichloride  gauze,  or  the  drainage  may  be 
kept  up,  either  from  the  start,  or  after  the  removal  of  the  gauze  by 
a  self-retaining  tube.  This  is  easily  prepared,  as  shown  in  Fig.  46, 
page  115,  a  T  being  formed.  The  arms  of  this  T  are  together  clasped 
in  the  tip  of  long  forceps  by  means  of  which  the  tube  is  carried  through 
the  orifice  at  the  vault  of  the  vagina  and  the  fiaps  allowed  to  expand 
in  the  pus  cavity.  A  tube  thus  made  and  inserted  may  be  worn  for 
a  week  or  even  months  without  removal  (Fig.  226). 

The  inguinal  or  inguino-vaginal  incision  is  practised  in  certain 
cases  where  the  pus  has  accumulated  in  the  retroperitoneal  structures. 


TREATMENT  OP  INFECTIONS  OF  THE  FALLOPIAN  TUBES     543 

and  has  lifted  up  and  practically  obliterated  the  folds  of  the  broad 
ligament.  Such  accumulations  occasionally  occur  in  positions  so  re- 
mote from  the  vagina,  and  so  distinctly  above  or  surrounding  the 
important  blood  vessels  to  the  side  of  the  uterus,  that  it  is  necessary 
to  avoid  the  vaginal  avenue  of  approach.  It  sometimes  happens  that 
a  diagnosis  of  the  exact  condition  and  location  of  this  accumulation 
can  not  be  made  until  after  the  peritoneal  cavity  has  been  opened. 
The  median  incision,  therefore,  merely  subserves  an  exploratory  pur- 


FiG.  226. — "  A  tube  thus  made  and  inserted  may  be  worn  for  weeks  or  even  months  without 
removal." — Keed  (page  542). 

pose.  With  the  finger  on  the  inside  of  the  peritoneal  cavity  and  acting 
as  a  guide,  an  incision  is  made  along  the  line  of  Poupart's  ligament, 
just  above  its  upper  border,  3  to  5  centimetres  in  length.  This  incision 
is  carried  down  through  the  fascia,  below  the  peritoneal  duplication, 
which  is  lifted  by  either  the  finger  or  a  blunt  dissector  or  the  handle 
of  a  bistoury,  the  instrument  thus  employed  being  pushed  forward 
until  the  pus  cavity  is  reached.  The  operation  may  stop  at  this 
point,  the  pus  cavity  being  treated  by  careful  irrigation  with  a  saline 
solution  followed  by  peroxide,  and  then  by  95-per-eent  carbolic  acid, 
followcfl,  in  turn,  by  the  alcohol.  It  should  then  be  packed  with  gauze 
or  treated  with  drjiiiiagc  l)y  tube.     If  the  pus  pocket  has  been  found 


544 


A  TEXT-BOOK  OF   GYNECOLOGY 


: 


Fig.  22"? 


.  by  making  two  openings,  one  a  little  above 
the  other." — Reed. 


to  be  sacculated  and  to  contain  a  considerable  amount  of  granulation 
tissue,  it  is  probable  that  suppuration  will  be  more  or  less  indefinitely 
continued;  to  dispose  of  it,  it  would  be  better  to  secure  throvigh-and- 
through  drainage  and  thus  to  take  advantage  of  the  force  of  gravity  in 
disposing  of  the  discharge.  This  is  readily  done  by  introducing  within 
the  pus  cavity  the  index  finger  of  the  right  hand,  carrying  Eeed's 

dilator  through  to  the 
vaginal  vault  or  to  the 
fornix,  as  the  case  may 
be,  and  with  the  in- 
dex finger  of  the  other 
hand  acting  as  a  guide  in  the  vagina,  pushing  the  dilator  through 
and  into  that  canal.  The  removal  of  the  dilator  is  followed  by  the 
insertion  of  the  intravaginal  finger  into  the  pus  cavity.  The  lumen  of 
the  tube  between  these  perforations  should  be  obliterated  by  ligating, 
or  simply  dividing  off  and  everting  it.  This  is  readily  done  by  making 
two  openings,  one  a  little  above  the  other  (Fig.  227),  and  each  long 
enough  to  permit  the  passage  of  a  tube  of  similar  size  through  it.  The 
forceps  is  then  passed  through  each  opening  (Fig.  228),  the  end  of 
the  tube  is  folded  over  and  seized,  and  the  tube  is  drawn  through 

itself  (Fig.  229).  The  result  is 
that  we  have  practically  two 
tubes,  one  opening  upon  one  side 


Fig.  228. — "  The  forceps  is  then  passed  through 
each  opening." — Eeed. 


Fig.  229. — "  .  .  .  and  the  tube  is  drawn 
through  itself." — Reed. 


and  the  other  opening  upon  the  other  side  of  a  septum  (Fig.  230).  Thus 
made,  the  tube  is  carried  through  the  inguinal  opening,  through  the 
opening  in  the  cul-de-sac,  and  out  through  the  vagina  (Fig.  231).  The 
drainage  tube  should  be  kept  from  dropping  too  far  into  the  wound,  and 
from  thus  coming  out  through  the  vagina,  by  carefully  inserting  a  safety 
pin  through  one  side  of  the  tube  at  a  point  corres]3onding  to  the  cutane- 
ous surface.  The  superficial  incision  may  then  be  closed,  except  so 
much  of  it  as  is  required  for  the  accommodation  of  the  tube. 

Abdominal  and  abdomino-vag-inal  incisions  are  practised  for  the 
purpose  of  abdominal  drainage  in  cases  in  which  the  purulent  accumu- 


TREATMENT  OF  INFECTIONS  OF  THE  FALLOPIAN  TUBES     545 


lation  is  situated  beliind  the  peritoneum, 
and  is  so  large  that  the  hitter  is  pushed 
above  the  brim  of  the  pelvis  to  such  an 
extent  as  to  permit  the  fixation  of  the 
peritoneal  sac  to  the  margins  of  a  median 
abdominal  incision.  When  this  incision 
has  been  made  and  the  abscess  sac  is 
found  thus  presenting,  and  it  has  been 
determined  to  practise  drainage,  the  peri- 
toneal surface  of  the  sac  should  be  fixed 
either  by  a  few  interrupted  sutures  or  a 
single  continuous  suture  at  the  peritoneal 
margin  of  the  abdominal  incision.  After 
it  has  been  thus  fixed,  an  aspirator  needle, 
(Fig. .  332)  or  a  small  curved  trocar  may 
be  inserted  and  a  large  quantity  of  the  con- 
tained pus  drawn  ofl^.  After  this  has  been 
done,  the  cavity  should  be  opened  by  an 
incision,  inserting  the  finger  for  the  pur- 
pose of  careful  exploration  of  the  inside. 
The  pus  should  then  be  washed  out  and 
the  cavity  should  be  treated  as  indicated  in  the  preceding  paragraphs. 
If  it  is  deemed  desirable  to  practise  through-and-through  drainage, 
as  is  the  rule  in  the  majority  of  cases,  the  tube,  already  described, 
may  be   inserted   (Fig.    233)    by   observing   precisely   the    same   pre- 


FiG.  230.— ••  The  result  is  that  we 
have  practically  two  tubes,  one 
opening  upon  one  side  and  the 
other  upon  the  other  side  of  a 
septum." — Keed  (page  544). 


Fio.  231. — "Thus  made,  the  tube  is  carried  through  tlie  inguinal  opening,  through  the  open- 
ing in  the  cul-de-sac,  and  out  througli  the  vagina."     (The  uterus  is  cut  away  in  the 
drawing,  tlic  left  tuhc  being  sliown.) — Keeu  (page  544). 
36 


646 


A  TEXT-BOOK  OP   GYNECOLOGY 


cautions  as  already  indicated.     (See  Inguinal  and  Inguino-vaginal  In- 
cision.) 

Rectal  puncture  was  devised  by  the  elder  Byford  as  a  method  of 
election  in  those  cases  in  which  purulent  accumulations  seemed  to 
press  into  and  point  toward  the  rectum.     In  certain  of  these  cases 

a  digital  exploration  of  the  rectum  will  indi- 
cate a  soft  fluctuating  point.  Byford  in- 
serted an  aspirator  needle  at  this  point  and 
drew  oflE  the  pus,  and  in  certain  cases  even 
went  to  the  extent  of  making  a  more  pal- 
pable puncture.  It  was  a  convenient  point 
of  drainage  and,  contrary  to  what  may  be 
imagined,  did  not  result  in  the  formation  of 
a  fa3cal  abscess  or  fistula.  When,  however, 
the  latter  accident  did  occur,  as  has  hap- 
pened in  a  surprisingly  limited  number  of 
cases,  it  proved  to  be  so  embarrassing  as  to 
seriously  militate  against  the  expediency  of 
the  operation.  It  is  now  but  rarely  adopted. 
Aspiration  may  be  considered  as  a  means 
of  evacuating  to  a  certain  extent  an  accu- 
mulation of  pus,  rather  than  as  a  means  of 
drainage;  for  the  moment  the  needle  is 
withdrawn  the  escape'  of  pus  is  discontinued. 
It  may  be  used,  however,  with  a  degree  of 
safety  through  any  of  the  avenues  of  ap- 
proach at  the  most  presenting  point  of  a 
pelvic  abscess. 

Conservative  Operations  on  the  Tubes. — 
The  indicalioiis  for  conservative  operations 
on  the  tubes  are  more  limited  than  in  the 
case  of  the  ovaries,  since  the  main  object 
aimed  at  is  to  favour  conception.  Hence 
the  preservation  of  portions  of  the  tubes  im- 
plies that  the  uterus  and  one  or  a  part  of  one  ovary  are  left,  otherwise 
the  tubes  would  be  useless. 

There  can  be  little  room  at  the  present  day  for  discussion  as  to 
the  propriety  of  not  sacrificing  the  internal  generative  organs  entirely 
unless  they  are  hopelessly  diseased;  for  experience  has  proved  that, 
even  when  marked  pathologic  changes  are  present,  recovery  may  take 
place  without  impairment  of  function,  as  shown  by  the  persistence 
of  menstruation  and  the  occurrence  of  conception.  Surgeons  are  now 
most  concerned  with  the  question  of  the  limits  of  conservatism,  in 
which  there  is  much  room  for  the  exercise  of  the  individual  Judgment. 
The  objections  urged  against  the  preservation  of  portions  of  dis- 
eased tubes,  are  the  immediate  risk  of  septic  infection,  subsequent  exten- 
sion of  the  disease  requiring  a  secondary  operation,  and  the  probability 


Fig.  232. — Aspirator  (page  545). 


TREATMENT  OP  INFECTIONS  OF  THE  FALLOPIAN  TUBES  54,7 

of  the  reforming  of  fresh  adhesions.  Most  important  of  all,  from  the 
patient's  standpoint,  is  the  possibility  that  pain  may  be  only  tempo- 
rarily, or  not  at  all,  relieved.  These  points  the  surgeon  must  consider 
at  the  time  of  the  operation,  being  guided  in  his  decision  by  the  history 
of  the  case,  the  extent  of  the  disease,  the  result  of  the  bacteriological 
examination  of  fluid  retained  within  the  tubes,  and,  above  all,  by  the 
expressed  wishes  of  the  patient,  assuming  that  she  is  of  an  age  when 
child-bearing  is  still  possible.  In  general  it  may  be  stated,  according 
to  Coe,  that  when  the  operator  feels  reasonably  sure  that  no  extra  risk 
will  be  entailed,  a  portion  of  one,  or  of  both  tubes  should  be  left. 


Fig.  233.- 


-"  If  it  is  deemed  desirable  to  practise  through-and-througli  drainage, 
already  described,  may  be  inserted." — Keed  (page  545). 


the  tube, 


The  simplest  conservative  procedure  consists  in  liberating  adherent 
tubes  by  gently  separating  all  adhesions,  beginning  at  the  distal  end 
and  working  upward  with  the  fingers  or  blunt-pointed  scissors,  toward 
the  uterus,  care  being  exercised  not  to  tear  the  delicate  fimbriEe  (Fig. 
234).  The  tube  and  mesosalpinx  must  be  entirely  freed,  straightened, 
and  brought  up  to  the  normal  position.  A  fine  probe  should  then  be 
passed  down  to  the  uterus,  great  gentleness  being  necessary  to  avoid 
a  false  passage.  If  the  tube  tends  to  prolapse,  it  is  well  to  fix  it  to 
the  ovary  with  one  or  two  catgut  sutures,  which  should  include  the 
serous  coat,  at  a  point  near  the  fimbriated  end.  Fixation  of  the  latter 
to  the  surface  of  the  ovary  so  as  to  occlude  the  lumen,  may  result  in 
the  formation  of  a  tubo-ovarian  cyst. 


548 


A  TEXT-BOOK  OF   GYNECOLOGY 


The  distal  opening  of  the  tube  may  be  closed  either  by  adhesions, 
or  by  the  rolling  in  and  agglutination  of  the  fimbrige  without  enlarge- 
ment of  the  tube.  The  septum  is  laid  open  by  radiating  incisions  with 
scissors,  and  the  mucous  membrane  is  united  to  the  perineum  with 

two  or  three  interrupted 
sutures  of  fine  silk  or  cat- 
gut. If  fluid  escapes  on 
opening  the  tube,  the  sur- 
geon must  regulate  his 
procedure  according  to  its 
character.  Blood  or  serum 
fluid  may  be  evacuated  by 
gently  stripping  the  tube 
toward  its  distal  end  on  a 
pad.  Should  pus  be  pres- 
ent, it  may  still  seem  ad- 
visable to  save  one  tube, 
especially  if  the  bacterio- 
logical examination  shows 
that  it  is  sterile,  and  if  it 
is  necessary  to  remove  the 
other.  After  squeezing 
out  the  pus  the  tube  is 
syringed  out  with  normal 
saline  solution,  then  with 
pure  peroxide  of  hydro- 
gen, and  finally  with  salt 
solution.  The  tube  is 
catheterized  and  restored 
to  the  pelvis,  being  su- 
tured in  its  normal  posi- 
tion. 

When  the  outer  third 
or  half  of  a  tube  is  dis- 
eased, it  is  divided  straight  across  with  a  scalpel,  bleeding  points  being 
caught  with  forceps.  The  stump  is  catheterized  and  the  end  slit  upon 
two  sides;  the  mucosa  is  then  sutured  to  the  serous  covering  as  before. 
The  end  is  then  attached  to  the  surface  of  the  ovary  in  such  a  way 
that  it  can  not  become  occluded.  If  the  tube  is  generally  thickened 
or  nodular,  and  is  strictured  in  its  middle  third,  the  same  procedure 
is  applicable,  or  the  strictured  portion  may  be  excised  and  end-to-end 
anastomosis  performed,  as  in  resection  of  the  intestines. 

Tubal  abscesses  adherent  in  Douglas's  pouch  are  treated  like  other 
collections  of  pus  in  the  pelvis — by  vaginal  incision,  irrigation,  and 
drainage.  Kelly  has  suggested  the  treatment  of  such  cases  by  the  intra- 
peritoneal method,  by  opening  and  cleaning  the  pyosalpinx,  dropping 
the  tube  back  into  the  pelvis  and  draining  per  vaginam.    The  same  con- 


FiG.  234. — "  The  simplest  conservative  procedure  con- 
sists in  liberating  adherent  tubes  by  gently  sepa- 
rating all  adhesions." — Coe  (page  547). 


TREATMENT  OF  INFECTIONS  OF  THE  FALLOPIAN  TUBES    549 

servative  treatment  is  applicable  to  eases  of  tubal  abortion  in  which  the 
opposite  tube  must  be  extirpated  on  account  of  extensive  disease.  (See 
Surgical  Treatment  of  Sterility.) 

The  radical  treatment  of  suppurations  of  the  Fallopian  tubes  con- 
sists in  the  removal  of  the  affected  tube  or  tubes;  and,  when  the  infec- 
tion has  extended  to  the  ovaries  and  produced  destructive  changes  in 
those  organs,  they,  also,  are  removed. 

Salpingectomy. — While,  according  to  Doleris,  salpingitis  is  not  a 
recently  discovered  disease,  having  been  described  by  Spronius  and 
mentioned  by  Morgagni  in  his  thirty-eighth  letter,  its  surgical  treat- 
ment has  been  a  matter  of  but  recent  development.  It  is  curious  to 
note,  however,  that  according  to  Schlesinger  {Centralblatt  fur  Gynd- 
hologie)  a  successful  laparo-salpingotomy  was  performed  in  Eussia  in 
1784.  Dr.  Seydel  was  the  operator  and  the  patient  was  a  woman  aged 
forty-two,  the  mother  of  three  children,  and  had  aborted  two  years 
previously  to  the  disease  which  required  the  operation,  viz.,  a  small, 
round,  and  firm  tumour  observed  in  the  summer  of  1783.  It  was  situ- 
ated on  the  right  side  of  the  abdomen,  and  in  size  and  consistence  bore 
some  resemblance  to  the  uterus  in  the  third  month  of  pregnancy.  The 
tumour  grew  visibly,  especially  during  the  courses,  was  accompanied  b}' 
very  violent  pains,  and  finally  reached  the  size  of  the  head  of  a  two-year- 
old  child,  at  the  same  time  becoming  evidently  softer.  Vaginal  exami- 
nation showed  that  the  tumour  was  connected  with  the  uterus  by  a 
round  and  firm  pedicle.  In  the  winter  of  the  same  year  the  catamenia 
changed  in  type,  while  the  pains  occurred  also  in  the  intermenstrual 
period.  The  author  explained  to  his  patient  (a  student  at  his  course 
for  midwives)  that  he  believed  the  right  ovary  to  be  diseased  and,  in 
his  opinion,  not  to  be  curable  without  operation.  The  patient,  though 
informed  of  the  risk  of  the  operation,  consented. 

The  operation  was  performed  on  February  21,  1784,  in  the  town 
of  Sarepta,  situated  in  the  government  of  Astrakhan.  The  patient 
was  prepared  with  baths,  some  doses  of  light  laxatives  and  Peruvian 
bark;  before  the  operation  she  received  a  small  quantity  of  tincture 
of  opium  and  saffron,  syrup  of  white  poppy,  and  Hoffmann's  drops. 
After  dividing  the  external  abdominal  coverings  and  the  muscles  in  a 
line  drawn  from  the  umbilicus  to  the  right  inguinal  region  across  the 
middle  of  the  tumour,  the  author  severed  the  peritoneum  with  a  button 
bistoury,  guided  by  the  finger;  three  arteries  were  ligated;  the  pro- 
truding intestines  were  crowded  back  into  the  abdomen  by  means  of  a 
napkin  soaked  in  warm  milk;  the  spherical  tumour,  which  was  in- 
closed in  a  thick,  firm  capsule,  and  contained  a  fluctuating  fluid,  was 
connected  with  the  uterus  by  a  pedicle,  and  its  upper  limit  reached  the 
crest  of  the  ilium;  on  the  posterior  and  lower  surface  of  the  tumour 
the  greatly  enlarged  fimbrias  of  the  tube  were  perceptible.  The  lower 
and  lateral  surfaces  of  the  tumour  were  so  closely  adherent  to  the  ad- 
joining muscles  and  organs  that  it  could  not  be  isolated  as  desired;  the 
author,  tliercforo,  concluded  to  open  it.     Tliis  having  been  done  by  a 


550  A  TEXT-BOOK  OF   GYNECOLOGY 

long  incision,  there  exuded  a  thick,  sticky  fluid,  without  odour,  and  of 
chocolate  colour,  weighing  one  pound  and  a  half.  Careful  examina- 
tion proved  beyond  doubt  that  the  aiithor  had  to  deal  with  a  tumour 
of  the  tube  and  not  of  the  ovary:  "  Qua  quidem  investigatione  certo  et 
indubitato  cognovi  tumoris  huius  sedem  non  ovarium  fuisse,  sed 
tubam."  A  decoction  of  Peruvian  bark  and  a  solution  of  myrrh  were 
then  poured  into  the  cavity  of  the  tumour,  and  a  wad  of  charpie  soaked 
in  Balsamum  Arc^ei  was  placed  in  the  wound  of  the  wall  of  the  tumour. 
After  the  intestines  had  been  isolated  from  the  parietal  peritoneum 
by  pieces  of  linen  dipped  in  oil  of  rose,  the  author  bandaged  the  ex- 
ternal abdominal  wound  with  plaster  and  linen,  but  subsequently  closed 
it  by  "  sutura3  cruentee." 

This  ojDerator  seems  to  have  been  a  man  of  keen  surgical  intuitions, 
for  nothing  else  would  have  prompted  him  to  undertake  the  operation, 
while  his  subsequent  conduct  of  the  case  made  him  a  prophet  of  the 
latter-day  canons  of  surgery.  In  the  first  few  days  after  the  operation, 
he  endeavoured  to  secure  a  free  outflow  of  the  fluid  which  showed  a 
tendency  to  form  in  the  tumour  cavity,  to  aecomjjlish  which  he  had 
recourse  to  tents;  these  proved  inefficient  and  he  used  a  silver  tube, 
which  likewise  proved  inefficient,  when  the  zealous  surgeon  with  his 
mouth  to  the  wound  sucked  the  foetid  fiuid  from  the  cavity.  He  re- 
peated this  operation  four  times  daily,  the  patient  being  directed  to 
lie  in  the  interval  with  her  abdomen  turned  downward  to  favour 
drainage.  The  fever  was  thus  kept  down,  the  purulent  secretion  gradu- 
ally diminished,  the  odour  vanished,  the  wound  contracted,  and  the 
patient  recovered. 

The  scientific  recognition  of  these  morbid  states  and  their  treat- 
ment by  ablation  of  the  uterine  appendages  is  due,  however,  to  the 
masterly  genius  of  the  late  Lawson  Tait.  In  contributing  this  knowl- 
edge to  science,  this  great  surgeon  conferred  upon  womankind  a  boon 
equal  to  that  of  ovariotomy  itself.  This  achievement,  among  the 
many  which  stand  to  his  credit,  is  of  itself  sufficient  to  entitle  his  name 
to  a  place  upon  the  scroll  of  immortality.  That  the  operation  has 
been  abused,  does  not  militate  in  the  least  against  its  intrinsic  worth,  or 
against  the  fact  that  it  is  annually  the  means  of  restoring  to  life  and 
health  thousands  of  women  whose  untimely  death  could  not  otherwise 
be  averted.  It  was  Tait  who  first  insisted  that  pus  in  the  pelvis  was 
subject  to  precisely  the  same  laws  of  surgical  treatment  as  pus  in  any 
other  accessible  portion  of  the  body.  This  axiom,  the  acceptance  of 
which  was  strenuously  resisted  by  many  who  were  manifestly  unfa- 
miliar with  the  technique  necessary  for  carrying  it  into  execution,  has, 
in  the  twenty-five  years  which  have  elapsed  since  it  was  first  enun- 
ciated, been  accepted  by  the  entire  medical  profession.  To-day  there  are 
no  dissenting  voices.  The  extirpation  of  the  uterine  appendages,  how- 
ever, places  beyond  hope  of  redemption  the  loss  of  the  reproductive 
function.  This  is  always  a  matter  of  serious  moment,  and  is  a  result 
to  be  avoided  whenever  possible.     The  beneficent  impulses  of  the 


TREATMENT  OF  INFECTIONS  OF  THE  FALLOPIAN  TUBES     551 

medical  profession  have  naturally  become  active  in  efforts  to  avert  the 
extreme  destruction  induced  by  a  naturally  destructive  disease.  Efforts 
are,  therefore,  being  made  to  conserve  the  organs  and  to  perpetuate 
their  functions.  This  conservative  tendency,  however,  is  not  in  con- 
travention of  the  law  of  Tait,  for  the  elimination  of  pus  and  the  arrest 
of  infection  are  just  as  much  aimed  at  by  conservative  as  by  radical 
measures.  There  is  a  strong  probability  that  the  efforts  at  conservatism 
have  thus  far  resulted  in  a  larger  proportion  of  failures  to  arrest  the 
infectious  processes,  than  is  to  be  attributed  to  the  radical  operation; 
while  the  restoration  of  function,  particularly  as  it  relates  to  con- 
ception, while  realized  in  but  a  small  number  of  cases,  must  stand 
as  the  vindication  of  efforts  to  save  the  tubes  or  the  ovaries  in  whole 
or  in  j)art.  The  present  tendency  and  the  present  necessity,  as  stated 
by  Coe,  are,  not  so  much  to  ascertain  the  limitations  of  the  radical 
operation,  as  to  determine  just  when  the  recognised  conservative 
method  should,  and  should  not,  be  applied.  It  may  be  taken  as  a  rule 
to  which  there  are  but  few  exceptions,  that  a  tube  that  is  the  seat  of 
infection  resulting  in  purulent  accumulation,  associated  with  occlu- 
sion of  both  the  uterine  and  distal  orifices,  is  not  amenable  to  any  other 
treatment  than  that  of  extirpation.  The  exceptions  to  this  rule,  if 
there  are  any,  can  not  be  determined  before  operation.  It  has  not  yet 
heen  demonstrated  that  fimbria  that  have  been  curled  inward  and 
sealed  by  plastic  exudation,  have  ever  afterward  become  spontaneously 
disentangled  with  the  restitution  of  the  tubal  orifice;  nor  has  it  ever 
heen  demonstrated  that  a  Fallopian  tube  thus  sealed  can,  without  sur- 
gical intervention,  again  subserve  the  purposes  of  an  oviduct.  Con- 
servative measures,  such  as  drainage,  may  conserve  the  structural  in- 
tegrity of  the  tube,  but  they  can  not  be  expected  either  to  restore  or 
to  perpetuate  its  functions.  The  conservatism  thus  practised  must, 
therefore,  have  its  distinct  limitations.  The  expediency  of  conserving 
a  functionally  useless  structure,  which  thereafter  can  be  potent  only 
for  mischief,  is  open  to  serious  question.  The  restoration  of  tubes 
which  have  been  the  seat  of  former  infection  may  be  undertaken  as 
an  operation  of  election  in  cases  of  sterility,  in  which  the  re-establish- 
ment of  the  reproductive  function  is  a  matter  of  extreme  necessity. 
(See  Operative  Treatment  of  Sterility.) 

Tait's  operation  for  removal  of  the  Fallopian  tubes,  as  practised  by 
Tait  himself,  included  the  removal  of  the  ovaries,  and  is  known  as 
abdominal  salpingo-odphoredomy.  There  were  several  reasons  why  the 
procedure  was  made  thus  comprehensive.  In  the  first  place,  the  ovaries 
were  generally  found  to  be  the  seat  of  disease  sometimes  as  active 
and  as  destructive  as  that  in  the  tubes  themselves;  in  the  next  place, 
an  ovary  without  a  tube  is  useless  for  reproduction;  in  the  third  place, 
an  ovary  left  in  position  may  subsequently  become  the  seat  of  neo- 
plastic or  degenerative  changes,  if  not  of  infection,  and  thus  be  a  source 
of  danger  to  the  patient;  and,  finally,  the  ovary  could  be  removed 
with  the  tube  without  adding  to  the  hazard  of  the  operation.     These 


552  A  TEXT-BOOK  OF  GYNECOLOGY 

reasons  seem  cogent  enough  and  are  yet  to  be  recognised  as  having 
extreme  weight.  Bland  Sutton  and  others,  however,  have  insisted  with 
reason  upon  the  importance  of  leaving  a  healthy  ovary  or  a  part  of 
an  ovary  m  situ,  to  avert  the  neurotic  storms  which  attend  the  sudden 
precipitation  of  the  menopause,  following  the  complete  ablation  of  the 
appendages.  This  innovation,  however,  does  not  modify  to  any  im- 
portant degree  the  essential  technique  of  the  operation. 

The  patient  is  prepared  and  the  incision  is  made  in  accordance 
with  the  directions  already  given  (see  x\bdominal  Section).  As  soon 
as  the  abdominal  cavity  is  opened,  the  patient  being,  during  the  entire 
operation,  in  the  dorsal  recumbent  posture,  the  surgeon  introduces  one 
or  two  fingers,  permitting  their  palmar  surface  to  glide  down  the 
parietal  peritoneum  over  the  collapsed  bladder  to  the  fundus  of  the 
uterus.  This  is  the  important  landmark  from  which  subsequent  ex- 
ploration of  the  pelvis  is  to  be  made.  Feeling  to  one  side  of  the 
uterus,  the  condition  of  the  Fallopian  tube  and  of  the  ovary  upon  that 
side  is  thoroughly  ascertained.  Going  back  to  the  fundus  of  the  uterus 
and  exploring  the  other  side,  the  other  tube  and  ovary  are  likewise 
examined.  It  is  sometimes  diihcult  to  outline  these  structures,  as  in 
the  presence  of  a  recent  inflammatory  exudation,  or,  in  the  presence 
of  old  and  firm  adhesions,  the  identity  of  tubes  and  ovaries  may  be 
lost  in  an  apparently  homogeneous  mass.  The  next  step  should  con- 
sist in  a  search  of  what  Joseph  Price  so  aptly  designates  as  a  point 
of  cleavage.  As  soon  as  this  is  found,  one  finger  should  be  used  to 
gradually  and  firmly,  but  gently  enucleate  the  inflammatory  mass  from 
the  parietal  peritoneum.  In  conducting  this  manipulation  it  is  im- 
portant, first,  to  have  obtained  a  correct  idea  of  the  approximate  loca- 
tion of  the  diseased  tube.  It  generally  occupies  a  position  behind  the 
posterior  fold  of  the  round  ligament,  or  even  in  the  cul-de-sac  of 
Douglas,  but  it  may  be  found  lying  between  the  uterus  and  the  bladder, 
or  attached  to  the  omentum,  or,  as  in  one  of  Eeed's  cases,  to  the  meso- 
colon {Cincinnati  Lancet-Clinic).  Care  should  be  taken — especially 
in  acute  cases  associated  with  high  temperature — to  avoid  rupturing 
the  pus  sac  and  thus  bathing  the  peritoneum  with  the  virulent  ele- 
ments of  infection.  This  accident  may  be  guarded  against  by  previously 
packing  the  pelvic  cavity  with  a  gauze  napkin,  which  should  be  so 
arranged  as  to  prevent  the  dissemination  of  the  pus.  When  the  tubes 
have  been  peeled  out  of  their  nests,  first  one  and  then  the  other  should 
be  brought  up  into  the  abdominal  incision.  The  pedicle  formed  by 
the  ovarian  ligament  and  the  broad  ligament  is  next  transfixed  by 
passing  through  the  broad  ligament  a  needle  loaded  with  the  ligature. 
Tait  employed  what  is  called  a  Staffordshire  knot.  This  consists  in 
bringing  the  loop  of  the  ligature  back,  over  and  around  both  the  tube 
and  the  ovary;  the  looped  end  is  then  placed  between  the  free  ends  of 
the  ligature  and  drawn  tight;  the  free  ends  of  the  ligature  are  then 
securely  tied  by  a  surgeon's  knot  and  are  cut,  leaving  not  less  than 
half  an  inch  beyond  the  knot.    In  applying  this  ligature,  care  is  taken 


TREATMENT  OP  INFECTIONS  OF  THE  FALLOPIAN  TUBES 


to  have  it  impinge  on  the  tube  at  its  uterine  juncture  and  to  have 
it  encircle  the  ovarian  ligament.  The  tube  and  ovary  are  then  cut 
away  by  scissors,  care  being  taken  to  leave  enough  of  the  pedicle  to 
prevent  the  slipping  of  the  ligature.  In  certain  of  these  cases  the  en- 
gorged mucosa  will  obtrude  from  the  pedicle,  in  which  case  it  should 
be  cauterized  by  passing  a  probe,  previously  immersed  in  pure  car- 
bolic acid,  into  its  lumen.  The  appendages  on  the  other  side,  if  dis- 
eased, are  treated  in  a  similar  way.  The  toilet  of  the  peritoneum  is 
now  made.  This,  as  practised  by  Tait,  consisted  in  flushing  the  peri- 
toneal cavity,  or  more  properly  the  pelvic  cavity,  with  pure  boiled 
water.  If  there  was  any  oozing  or  if  a  pus  tube  had  been  ruptured, 
Tait  inserted  a  glass  drainage  tube.  This  consisted  of  a  piece  of  glass 
tubing  long  enough  to  reach  from  the  cutaneous  margin  of  the  ab- 
dominal incision  to  the  floor  of  the  cul-de-sac;  it  had  a  number  of 
small  perforations  in  the  lower  2  or  3  centimetres  of  its  wall,  and 
it  was  made  to  flare  slightly  at  the  top.  Through  this  drainage  tube, 
blood  and  serum  was  pumped  by  means  of  a  suction  apparatus,  at  in- 
tervals varying  from 
half  an  hour  to  an 
hour  until  oozing 
ceased.  The  abdo- 
men was  then  closed 
by  interrupted  su- 
tures, Tait  using  silk 
both  for  the  pedicles 
and  for  the  abdom- 
inal incision.  Tait's 
dexterity  in  perform- 
ing this  operation 
was  the  marvel  of 
surgery  in  his  day. 
His  technique  is  to- 
day religiously  fol- 
lowed by  many  of  the 
most  eminent  and 
successful  operators. 

Modifications  of 
Tait's  operation  have 
altered  its  technique 
to  a  slight  degree 
without  in  the  least 
modifying  its  princi- 
ple. Thus,  the  Tren- 
delenburg position  is 

largely  employed.  The  ovaries  are  now  occasionally  left  in  situ,  the 
diseased  tubes  alone  being  removed — a  line  of  practice  which  is  yet  dis- 
tinctly in  its  experimental  stage.    A  hydrosalpinx  is  now  occasionally 


Fig.  235.- 


.  .  .  Draining  per  vaginam  ...  by  gauze  is  gen- 
erally preferred."— Keed  (page  554). 


554 


A  TEXT-BOOK  OF   GYNECOLOGY 


incised,  drained,  and  dropped  back — a  method  of  treatment  that  yet 
awaits  justification.  In  ligating  the  pedicle,  but  few  operators  now  em- 
ploy the  Staffordshire  knot,  those  who  still  cling  to  the  en  masse  method, 
preferring  to  use  that  known  as  the  figure-of-eight  ligature.  Many 
operators,  however,  prefer  to  control  the  ovarian  artery  primarily  by 
snap-forceps,  and  then,  after  cutting  away  the  ovary  and  the  tube,  to 
ligate  the  vessel,  with  its  associated  veins,  individually;  the  peritoneal 
folds  of  the  broad  ligament  being  sutured  over  the  ligated  extremities  of 
the  vessels.  Catgut  is  now  very  generally  employed  instead  of  silk  for 
both  ligatures  and  sutures.  Drainage,  in  the  presence  of  assured  hemo- 
stasis,  is  but  rarely  employed,  and  when  it  is,  Martin's  method  of  open- 
ing the  floor  of  the  cul-de-sac  and  draining  per  vaginam,  either  by  a 
self-retaining  tube  or  by  gauze,  is  generally  preferred  (Fig.  235).  In 
the  presence  of  persistent  oozing,  a  gauze  pack  is  sometimes  adjusted 


Fig.  236. — "In  the  presence  of  persistent  oozing,  a  gauze  pack  is  sometimes  adjusted." — Keed. 


(Fig.  236).  The  toilet  of  the  peritoneum  is  now  generally  made  by 
means  of  pieces  of  dry  sterilized  gauze,  by  which  the  cavity  is  mopped 
out.  The  abdominal  incision  is  noAv  closed  by  many  operators  by  means 
of  the  laminated  suture.    (See  Abdominal  Section.) 

Abdominal  panhysterectomy  has  been  adopted  by  many  operators 
(Fig.  237)  for  the  radical  treatment  of  purulent  infections  of  the 
uterus  and  adnexa.  The  technique  does  not  differ  in  any  particular 
from  that  already  described.     (See  Abdominal  Panhysterectomy.) 

The  reasons  for  adopting  this  operation  are  practically  those  which 
prompted  Doyen,  Pean,  Segond,  and  the  French  school  in  general. 


TREATMENT  OP  INFECTIONS  OF  THE  FALLOPIAN  TUBES  555 

to  adopt  vaginal  hysterectomy  in  these  cases.  In  the  first  place,  in 
certain  of  the  infections,  notably  that  by  the  streptococcus  (see  Strep- 
tococcous  Infection  of  the  Uterus),  the  parenchyma  of  the  uterus  is 
invaded,  with  the  result  that  more  or  less  permanent  changes  are  estab- 


FiG.  287. — ''  AbdomiDal  panhysterectomy  has  been  adopted  by  many  operators  .  .  ." — Reed 

(page  554). 

lished;  even  in  cases  of  gonococcous  infection,  in  which  the  patho- 
logic changes  have  been  manifested  in  the  deep  utricular  glands  and 
in  the  muscular  stroma  with  which  they  are  surrounded,  hyperplasias  of 
a  more  or  less  j^ermanent  character  are  established.  These  are  the 
cases  which  furnish  the  distressing  examples  of  persistently  pain- 
ful uteri  following  ablation  of  the  appendages.  It  is  to  be  acknowl- 
edged that  the  removal  of  pus  tubes  does  not  restore  many  of  these 
cases  to  even  symptomatic  health.  In  many  cases  an  infected  uterus, 
in  spite  of  repeated  curettage,  remains  an  infected  uterus  after  the 
removal  of  the  diseased  appendages.  For  this  reason  the  French  school 
of  surgeons,  with  practical  unanimity,  has  adopted  the  practice  of 
removing  the  diseased  uterus  with  the  diseased  adnexa.  The  results 
have  justified  the  practice.  According  to  the  observation  of  Eeed, 
the  primary  surgical  recovery  from  this  operation  is  more  uniform 
and  attended  with  fewer  embarrassing  incidents  than  that  following 
the  ablation  of  the  appendages.  The  choice  between  panhysterectomy 
and  supravaginal  amputation  in  these  cases  rests  upon  no  debatable 
ground.  If  the  operation  is  undertaken  because  of  infection  of  the 
uterus,  it  would  be  manifestly  improper  to  leave  a  part  of  that  in- 
fected organ  in  situ,  particularly  when  its  complete  removal  can  be  as 
■easily  and  as  safely  effected.  Reed  prefers  the  abdominal  to  the  vaginal 
section,  for  the  reason  that  it  places  all  possible  complications  under 
more  complete  control.  Doyen  admits  that  abdominal  section  is  the 
operation  of  choice  in  the  presence  of  large  adnexal  tumours  and  also 
of  probable  tuberculous  peritonitis.  Pryor,  with  equal  frankness, 
acknowledges  that  vaginal  ablation  should  not  be  attempted  in  the 
presence  ol;  coruplicuting  intestinal  lesions.    In  these  acknowledgments 


556  A  TEXT-BOOK  OP  GYNECOLOGY 

are  found  important  limitations  of  the  vaginal  method,  and  equally 
important  reasons  why  the  operation  should  be  done  by  abdominal 
section.  The  frequency  with  which  unsuspected  adhesions  between  the 
tubes  and  the  intestines  are  encountered,  and  the  known  impossibility 
of  diagnosticating  all,  or  even  a  majority  of  these  cases,  before  explora- 
tory incision,  constitutes  sufficient  reason  for  invading  these  cases  from 
above.  The  remoteness,  in  an  anatomical  sense,  of  many  of  these  com- 
plications renders  impossible  their  detection  by  vaginal  exploration. 
Eichelot,  a  former  partisan  and  present  friend  of  vaginal  hysterectomy, 
states  {Annals  of  Gynecology  and  Pediatry)  that  in  1  out  of  every 
3  cases  in  which  he  did  vaginal  exploratory  incision,  he  found  con- 
ditions which  rendered  the  other  route  more  desirable,  and  that  he 
consequently  had  occasion  to  regret  his  diagnostic  ability,  but  "to- 
day," he  adds  with  captivating  naivete,  "  I  no  longer  have  any  regrets, 
because  total  abdominal  hysterectomy  gives  me  complete  cures."' 
Miller  {Bulletin  of  the  Johns  Hopkins  Hospital)  concludes,  after  a  care- 
ful bacteriological  examination  of  68  uteri  removed  by  operation,  that 
"  in  uncomplicated  cases  of  hystero-myomectomy,  hysterectomy  for 
inflammatory  cases  or  ovarian  tumours,  in  operations  for  extra-uterine 
pregnancies,  and  in  all  such  cases  where  the  vagina  and  cervix  were 
normal  except  probably  for  invasion  by  the  gonococcus,  the  safest 
route  so  far  as  infection  is  concerned  is  the  abdominal."  Miller,  how- 
ever, fails  to  explain  why  invasion  by  the  gonococcus  should  be  made 
an  exception.  Zweifel  employs  the  abdominal  method  of  complete 
hysterectomy,  and  in  65  of  his  cases,  studied  by  Abel  and  reported 
in  1894,  both  the  primary  and  ultimate  results  were  uniformly  satis- 
factory. Fritsch,  Martin,  and  Jacobs,  object  to  the  retention  of  the 
cervix  or  any  part  of  it  in  hysterectomy  for  infections  involving  the 
uterus  and  appendages,  urging  as  a  reason  for  their  position,  that  the 
cervical  mucosa,  however  carefully  treated,  may  act  as  the  nidus  of 
infection,  which,  under  such  circumstances,  may  and  frequently  does 
invade  the  field  of  operation. 

Doyen's  operation  for  infections  of  the  Fallopian  tubes  consists  in 
a  vaginal  hysterectomy  including  the  removal  of  the  Fallopian  tubes 
and  the  ovaries  with  the  uterus.  The  operation  was  first  done  for  this 
purpose  in  1887,  although  Doyen  had  previously  adopted  practically 
the  same  technique  for  nonsuppurative  diseases  of  the  appendages. 

The  operation  is  performed  by  placing  the  patient  upon  her  back 
with  her  knees  well  flexed,  when  the  perineum  is  retracted  and  the 
cervix  is  seized  with  a  strong  forceps,  one  forceps  being  applied  to 
each  lateral  lip.  The  cervix  is  now  drawn  down  by  firm  traction  and 
an  incision  is  made  in  the  posterior  cul-de-sac  by  means  of  curved 
scissors,  a  bistoury  never  being  employed.  The  peritoneum,  if  free, 
is  opened  by  the  second  or  third  cut  of  the  scissors,  permitting  the 
escape  of  a  few  grammes  of  normal  peritoneal  fluid.  The  right  index 
finger  is  now  introduced  into  the  serous  button-hole  for  the  purpose  of 
exploring  the  posterior  surface  of  the  uterus  and  that  of  the  append- 


TREATMENT  OP  INFECTIONS  OF  THE  FALLOPIAN  TUBES    557 

ages.  If  adhesions  are  found  to  exist  in  a  moderate  degree,  they  are 
broken  up  so  far  as  they  can  be  reached.  This  preliminary  explora- 
tory incision  is  insisted  upon  as  an  essential  part  of  the  technique,  and 
as  the  means  by  which  it  is  to  be  determined  whether  to  conclude  the 
operation  by  the  vaginal  route  or  to  make  an  abdominal  section.  The 
condition  of  the  proximal  serous  surfaces,  the  fundus  of  the  uterus, 
the  sacto-salpinx  if  it  exists,  and  the  ovaries,  may  thus  be  readily 
explored.  If  the  cul-de-sac  is  obliterated  by  inflammatory  adhesions, 
the  latter  may  be  broken  up  by  passing  the  finger  with  its  palmar 
surface  to  the  uterus.  The  exploration  of  the  true  pelvis  being  com- 
pleted, and  fluid  accumulations  being  evacuated,  it  is  easy  to  determine 
whether  or  not  to  complete  the  operation.  The  radical  operation  being 
decided  upon,  the  cervix  is  drawn  downward  and  backward,  a  short- 
bladed  retractor  is  introduced  anteriorly,  and  the  circum-cervical  in- 
cision is  completed  with  the  scissors.  The  bladder  is  separated  with 
the  right  index  finger  as  high  and  as  far  to  either  side  as  possible.  The 
uterus  is  then  isolated  before  and  behind  from  any  neighbouring  organs 
to  which  it  may  be  attached.  The  neck  is  drawn  down  near  the  vulva, 
when,  with  scissors,  the  anterior  wall  is  split  from  the  cervix  to  the 
anterior  peritoneal  cul-de-sac.  This  now  comes  into  view  and  is  freely 
divided,  after  which  the  median  semisection  is  carried  to  the  fundus 
of  the  uterus.  At  this  stage  a  loop  of  the  intestine,  of  the  omentum 
or  the  sigmoid,  or  sometimes  of  the  vermiform  appendix,  may  be  found 
adherent  to  the  uterus,  or  may  be  drawn  down  beneath  the  retractor. 
If  this  is  found  to  be  the  case,  the  isolation  of  the  fundus  of  the  uterus 
is  easily  made  under  vision.  The  body  of  the  uterus  is  easily  everted, 
the  cervix  hanging  over  the  fourchette.  The  appendages  on  both 
sides  are  now  explored  with  the  index  finger  and  their  extirpation 
can  be  undertaken,  beginning  upon  either  side,  at  the  choice  of  the 
operator.  It  is  well  to  begin  by  utilizing  the  index  finger  to  break 
down  any  remaining  adhesions,  after  which  the  tube  and  ovary  may 
be  readily  drawn  down  by  moderate  traction,  after  being  seized  by  the 
index  and  little  fingers.  If  there  are  serous  cysts,  or  if  the  purulent 
accumulations  are  too  large,  it  is  easy  to  evacuate  them  in  the  course 
of  the  manoeuvres.  It  is  exceptional  when  the  extraction  of  the 
adnexa  by  this  manipulation  is  not  complete.  A  clamp  is  then  applied 
above  and  below  to  each  broad  ligament;  a  smaller  clamp  being  applied 
outside  each  larger  clamp,  to  prevent  the  retraction  of  the  pedicle. 
Care  should  be  taken,  in  applying  the  small  forceps,  to  seize  the 
uterine  and  ovarian  vessels  respectively.  Doyen  removes  the  large 
clamps  at  the  end  of  four  hours  and  the  smaller  ones  after  ten  hours. 
The  sterilized  gauze  with  which  the  vagina  is  packed  up  to  the  peri- 
toneum, is  permitted  to  remain  in  situ  until  the  third  or  fourth  day. 
Beginning  on  the  fifth  day,  unless  sooner  indicated,  vaginal  injec- 
tions are  practised  to  the  extent  of  five  or  six  every  twenty-four  hours. 
Modifications  of  Doyen's  operation  have  been  adopted  by  various 
operators.    Pean  commenced  the  operation  by  isolating  the  cervix  from 


558  A  TEXT-BOOK  OP   GYNECOLOGY 

the  vaginal  mucosa  and  by  applying  hemostatic  forceps  to  the  uterine 
arteries  on  each  side.  He  divided  the  cervix  bilaterally,  thus  forming 
an  anterior  and  a  posterior  flap;  these  were  then  seized  by  a  fresh  grip 
of  the  volsella,  by  which  progressive  traction  was  exercised  upon  the 
uterus.  As  the  organ  was  dragged  down,  the  lateral  tissues  were  seized 
by  hemostatic  forceps  and  the  lateral  incisions  of  the  uterine  wall  were 
carried  step  by  step  to  the  fundus.  The  obvious  objection  to  this 
method  is  the  absence  of  the  preliminary  exploration  practised  by 
Doyen,  and  the  use  of  a  large  number  of  useless  clamps  to  encumber 
the  field  of  operation  and  to  render  difficult  that  which  ought  to  be 
easily  accomplished.  Pryor,  who  has  done  more  than  any  one  man  to 
introduce  the  vaginal  method  of  operation  in  America,  has  adopted 
several  important  innovations.     He  utilizes  the  procedure  of  Landau 


Fig.  238. — Pryor  "  has  invented  and  employs  a  very  valuable  traction  forceps." — Reed. 

in  making  complete  semisection  of  the  uterus — i.  e.,  dividing  not  only 
the  anterior  wall,  as  does  Doyen,  but  the  posterior  wall  also.  He  has 
invented  and  employs  a  very  valuable  intrauterine  traction  forceps 
(Pig.  338). 

Por  splitting  the  uterus,  he  uses  large  curved  grooved  directors, 
one  being  passed  above  and  behind  the  uterus  anteriorly,  and  another 
posteriorly,  care  being  taken  that  no  fold  of  intestine  or  of  omentum 
is  caught  between  this  director  and  the  uterus.  A  probe-pointed, 
slightly  curved  bistoury  is  now  used  for  dividing  the  uterus,  the  blunt 
point  following  the  groove  in  the  directors.  First,  one  half  of  the 
uterus  with  its  adnexa  is  drawn  down,  and  the  broad  ligaments  are 
secured  by  clamps,  in  the  application  of  which  great  care  is  exercised. 
One  clamp  is  applied  to  the  upper  margin  of  the  broad  ligament,  and 
is  locked  with  its  point  embracing  about  the  upper  half  of  the  ligament, 
care  being  taken  that  the  ovarian  artery  is  included  in  its  grip;  the 
other  forceps  is  applied  to  the  lower  half  of  the  broad  ligament,  care 
being  taken  that  the  uterine  artery  is  embraced  within  its  grip.  In 
this  way  the  broad  ligament  folds  upon  itseM  without  injury.  The 
pelvis  is  now  packed  with  sterilized  gauze  pads  secured  by  strings  with 
which  to  facilitate  their  removal.    Le  Bee  ligates  the  pedicles  and  draws 


TREATMENT  OP  INFECTIONS  OP  THE  FALLOPIAN  TUBES     559 

them  down  into  the  vagina;  and^  in  cases  in  which  there  is  no  probable 
remaining  infection  of  the  pelvic  cavity,  the  ends  of  the  broad  liga- 
ments are  drawn  together  on  the  median  line,  thus  closing  the  peri- 
toneal cavity. 

The  indications  and  limitations  of  Doyen's  operation  should  be 
understood.  The  raison  d'etre  of  the  operation  is  the  fact  that  the 
results  following  ablation  of  the  appendages  are  not  always  satisfactory. 
This  depends  upon  permanent  changes  in  the  muscularis  of  the  uterus 
and  in  its  lining  membrane,  causing  the  organ  to  be  persistently  painful 
after  the  removal  of  the  diseased  adnexa.  In  the  presence  of  acute 
streptococcous  infection  of  the  uterus  and  the  Fallopian  tubes,  the  indi- 
cations for  complete  ablation  are  positive;  while  in  the  presence  of  long- 
standing chronic  infection  of  both  the  uterus  and  the  tubes  the  indica- 
tions are  almost  equally  strong.  In  many  cases  belonging  to  the 
latter  class,  the  uterus  not  only  remains  painful,  but  is  a  persistent 
fons  et  origo  of  a  purulent  discharge  which  can  not  be  controlled  even 
by  repeated  curettage.  The  result  is  a  failure  to  restore  the  patient 
to  health.  The  preservation  of  the  now  functionally  useless  womb  is 
no  argument  against  the  operation.  The  procedure,  however,  has  its 
limitations.  Eichelot,  while  personally  preferring  vaginal  hysterec- 
tomy, recognises  its  limitations  and  practises  abdominal  panhysterec- 
tomy. Doyen  says  that  abdominal  section  is  indicated  in  the  presence 
of  large  tumours  of  the  adnexa  and  in  the  presence  of  probable  tuber- 
culous peritonitis.  Pryor  concludes  that  vaginal  ablation  should  not 
be  attempted  through  a  vagina  so  narrow  as  to  necessitate  incision  of 
the  perineum,  as  practised  by  Segond.  He  also  states  that,  in  the 
presence  of  complicating  intestinal  lesions,  the  latter  are  to  be  recog- 
nised as  the  principal  indication  for  intervention,  which  under  these 
circumstances,  should  be  done  exclusively  by  abdominal  section.  He 
fails  to  state,  however,  just  how  these  complications  may  always  be 
recognised.  The  personal  preference  of  the  operator,  and  his  familiar- 
ity with  a  given  technique,  must  always  be  recognised,  however,  as  a 
cogent  reason  for  its  employment. 


CHAPTER  XXXVI 

MALFORMATIONS  AND   DISPLACEMENTS  OF   THE   OVARIES 

Malformations:    Absence;   rudimentary  development;   accessory  ovaries;   coexist- 
ence of  ovaries  and  testicles— Displacements :  Descensus ;  prolapsus ;  hernia. 

Malformations  of  the  Ovaries. — Since  the  ovary,  like  the  testicle, 
begins  its  development  at  a  higher  level  in  the  abdomino-pelvic  cavity 
than  that  which  it  iTltimately  occupies,  cases  occur  in  which  its  descent 
has  been  arrested,  and  in  which  it  is  found,  in  the  adult,  above  the 
plane  of  the  pelvic  brim.  Since,  further,  the  ovary,  unlike  the  testicle, 
does  not  normally  pass  into  the  inguinal  canal,  it  must  be  counted  as 
a  displacement  when  it  is  met  with  in  that  canal,  or  beyond  it  in  the 
substance  of  the  labium  majus.  The  ovary,  also,  is  liable  to  malforma- 
tions by  defect  and  by  excess. 

Absence  of  the  Ovary. — Complete  absence  of  both  ovaries  in  an 
individual  furnished  with  a  uterus  and  external  genital  organs  of  the 
female  type,  must  be  regarded  as  an  almost  undemonstrated  occurrence. 
For  its  demonstration,  it  would  be  necessary  to  examine  post  mortem, 
not  only  the  pelvic  cavity,  but  also,  and  with  great  thoroughness,  the 
abdominal  cavity  as  well.  Its  occasional  occurrence  in  grossly  de- 
formed foetuses  is,  however,  beyond  doubt.  The  absence  of  one  ovary 
is  not  so  uncommon,  and,  when  met  with,  is  usually  associated  with 
defect  of  the  corresponding  Miillerian  duct  (absence  of  the  Fallopian 
tube,  uterus  unicornis,  and  unilateral  vagina),  and  sometimes  with  ab- 
sence of  the  corresponding  kidney  (as  in  the  case  reported  by  Dela- 
geniere,  Progres  medical,  2.  s.,  vol.  xx,  p.  256,  1894). 

Rudimentary  State  of  the  Ovary. — Although  actual  absence  of  the 
ovaries  may  be  one  of  the  extreme  rarities  of  teratology,  functional 
absence  (i.  e.,  their  rudimentary  state)  is  a  well-established  and  not 
very  uncommon  maldevelopment.  The  glands  may  be  so  ill-developed, 
and  may  show  such  an  approximation  in  their  microscopical  characters 
to  the  appearances  seen  in  the  earliest  period  in  intrauterine  life,  that 
it  may  be  difficult  to  decide  from  their  examination  alone  whether  they 
are  ovaries  or  testicles.  In  form  they  may  resemble  the  foetal  or  in- 
fantile type,  and  they  may  be  associated  with  the  foetal,  the  infantile, 
or  the  bicornate  uterus.  Further,  they  may  coexist  with  other  an- 
omalies such  as  rudimentary  tubes,  stenosis  of  the  aorta,  and  hypo- 
plasia of  more  distant  organs.  Eudimentary  development  is  also  often 
combined  with  congenital  displacement,  which  is  indeed  itself  a  form 
560 


MALFORMATIONS  AND   DISPLACEMENTS   OP  THE  OVARIES    561 


of  rudimentary  development.  If  one  ovary  alone  is  in  a  rudimentary 
state^  the  anomaly  may  not  appreciably  influence  the  reproductive  life- 
history  of  the  individual  in  whom  it  exists;  but  if  both  glands  are 
imperfect,  the  menstrual  flow  is  either  entirely  absent,  or  is  imperfectly 
established,  there  is  defective  hirsute  development  on  the  mons  veneris, 
there  is  absolute  sterility,  and  there  is  a  condition  of  general  infantil- 
ism with  or  without  chlorosis  and  vascular  hypoplasia.  Cases  have, 
however,  been  put  on  record,  in  which  the  rudimentary  state  of  the 
ovaries  has  been  associated  with  a  normal  development  of  the  uterus 
and  with  all  the  signs  of  general  bodily  and  mental  vigour,  and  even 
with  indications  of  sexual  desire.  The  diagnosis  of  the  anomalous  con- 
dition of  the  genital  glands  may  be  made  provisionally  from  a  con- 
sideration of  the  symptoms,  but  with  certainty  only  by  means  of  a 
laparotomy.  Manifestly,  if  it  exists  in  association  with  rudimentary 
development  of  the  uterus,  it  will  be  of  little  use  to  spend  time  and 
energy  in  therapeutical  efforts  directed  against  the  latter  organ.  Where 
acute  menstrual  sufferings  and  marked  nervous  phenomena  of  the 
nature  of  epilepsy  and  insanity  exist,  it  may  be  well  to  consider  the 
question  of  removal  of  the  rudimentary  ovaries;  but  it  by  no  means 
follows  that  the  nervous  manifestations  will  cease,  for  they  can  not 
always  be  regarded  as  consequences  of  the  ovarian  defect;  indeed,  they 
and  the  defect  may  quite  possibly  be  the  results  of  a  common  cause. 
Rudimentary  ovaries 
may  be  due  to  ar- 
rested development 
during  the  embry- 
onic period  of  intra- 
uterine life,  or  to 
peritonitis  during 
the  fcetal  epoch,  or 
to  ovaritis  from  the 
supervention  of  one 
of  the  exanthemata 
in  childhood. 

Accessory  Ova  - 
ries. — With  the  ex- 
ception of  the  case 
of  third  ovary  de- 
scribed by  Winckel 
(Lehrhuch,  p.  595, 
1886),  no  genuine 
example  of  duplica- 
tion of  the  female  genital  gland  has  been  put  on  record,  and  even 
Winckel's  case  is  in  the  opinion  of  Nagel  (in  Veit's  Ilandbuch  der 
Gyniikolof/ie,  Bd.  i,  p.  562,  1897)  open  to  doubt  by  reason  of  the  presence 
of  gland  ducts  in  the  supposed  ovarian  body.  On  the  other  hand, 
accessory  ovaries,  or,  as  it  is  more  cori-ect,  perhaps,  to  name  them,  "  con- 
37 


Fig.  239. — "'Constricted  ovaries'  are  much  less  rare."     (Der- 
moid cyst  in  constricted  portion.) — Ballantyne  (page  562). 


562  A  TEXT-BOOK  OF   GYNECOLOGY 

stricted  ovaries  "  (Fig.  239)^  are  much  less  rare.  One  such  ovarian  frag- 
ment was  seen  by  Ballantyne  and  Williams  in  a  series  of  61  consecutive 
autopsies  on  females  dying  in  the  Edinburgh  Eoyal  Infirmary;  it  was 
as  large  as  a  j^ea  and  was  made  up  of  ovarian  stroma  with  Graafian 
follicles;  it  was  attached  to  the  anterior  border  of  the  right  ovary 
by  a  stalk  consisting  jjartly  of  fibrous  tissue  with  a  covering  of  low 
cubical  epithelium,  and  partly  of  solid  colunms  of  epithelial  cells 
inclosed  in  the  fibrous  tissue;  and  it  showed  a  cicatrix  pointing  to  the 
dehiscence  of  a  Graafian  follicle  at  some  time  in  the  life  of  the  indi- 
vidual. As  many  as  three  accessory  ovaries  have  been  found  in  one 
case,  and  an  ovary  has  been  noted  divided  into  two  almost  equal  parts. 
It  is  supposed  that  the  constriction  of  the  ovarian  substance  is  pro- 
duced by  foetal  peritonitis.  Clinically,  accessory  ovaries  are  of  im- 
portance in  explaining  the  want  of  success  which  sometimes  follows 
removal  of  the  ovaries  performed  in  order  to  induce  a  premature 
menopause;  they  also  offer  an  explanation  of  the  occurrence  of  preg- 
nancy after  a  double  ovariotomy,  and  of  the  jDresence  of  three  (or  more) 
separate  ovarian  cystomata. 

Coexistence  of  Ovaries  and  Testicles  in  the  Same  Individual. — The 
presence  of  one  ovary  and  one  testicle  or  of  two  ovaries  and  two  testicles 
in  the  same  individual,  constitutes  the  anomalous  condition  described 
as  true  hermaphroditism.  Of  the  hilateral  form  (that  in  which  an 
ovary  and  testis  are  present  upon  both  sides  of  the  body),  no  abso- 
lutely conclusive  example  in  the  human  subject  has  yet  been  recorded; 
the  two-months'  old,  premature,  and  otherwise  malformed  infant  de- 
scribed by  Heppner  (Archiv  fiir  Anaiomie,  Physiologie,  unci  wissen- 
scliaftliche  Medicin,  p.  679,  1870)  had  a  rudimentary  uterus  and  a 
vagina,  and,  on  both  sides,  a  normal  ovary,  parovarium,  and  tube,  and 
near  to  each  ovary  was  a  body  resembling  a  testis  and  containing 
tubules  running  toward  the  hilum;  but  whether  the  last-named  bodies 
were  really  testicles,  is  a  hard  question  to  settle,  especially  as  the 
drawings  are  unsatisfactory.  Lateral  hermaphroditism,  which  may  be 
defined  as  the  presence  of  an  ovary  on  one  side  and  a  testis  on  the 
other,  has  been  met  with  in  a  few  cases,  of  which  those  reported  by 
Obolonsky  (Zeifschrift  fiir  HeiTkunde,  vol.  ix,  p.  211,  1888)  and  Schmorl 
(Archiv  fiir  patliologisclie  Anatomie  und  Physiologie,  etc.,  vol.  cxiii,  p. 
229,  1888)  are  the  most  clearly  established.  In  SchmorPs  patient,  an 
individual  twenty-two  years  of  age,  there  was  hypospadias,  which  was 
successfuly  operated  upon;  a  swelling  appeared  in  the  groin,  which  was 
regarded  as  a  degenerate  testis  and  was  excised,  but  death  occurred. 
At  the  autopsy,  it  was  found  that  the  body  in  the  left  groin  was  an 
ovary,  there  was  a  uterus  bicornis,  and,  on  the  right  side  in  the  scrotum 
was  a  testis  with  a  rudimentary  epididymis.  Blacker  and  Lawrence 
{Transactions  of  the  Obstetrical  Society  of  London,  vol.  xxxviii,  p.  265, 
1896)  have  described  what  is  apjDarently  the  only  genuine  case  of  unilat- 
eral hermaphroditism  (ovary  or  testis  on  one  side,  with  ovary  and  testis 
on  the  other)  in  the  human  subject.    The  case  was  that  of  a  foetus,  other- 


MALFORMATIONS  AND   DISPLACEMENTS   OF  THE  OVARIES     563 

wise  well  formed^  in  which  was  found  a  uterus  iinicornis,  a  normal 
ovary  and  tube  on  the  right  side,  and  on  the  left  side  an  ovo-testis, 
with  a  vas  deferens  and  epididymis.  The  left  gland  (ovo-testis)  in  one 
part  showed  cell  columns,  cell  nests,  and  Graafian  follicles  with  a 
large  quantity  of  stroma  (ovarian  portion);  and  in  a  second  part  ex- 
hibited an  abundant  stroma,  with  definite  tubules  filled  with  cells, 
and  forming  at  the  hilum  a  retelike  structure  (testicular  portion). 
It  may,  therefore,  be  accepted  that  the  occurrence  of  what  may  be 
termed  anatomic  hermaphroditism  in  the  human  subject  has  been 
demonstrated — that  is  to  say,  in  one  individual  genital  glands  have  been 
found,  one  of  which  had  a  structure  which  could  be  justly  called 
ovarian,  while  the  other  showed  appearances  warranting  the  conclusion 
that  it  was  testicular  in  nature.  No  case,  however,  has  yet  been  met 
with  in  which  functional  hermaphroditism  was  present — ^that  is  to  say, 
no  individual  has  ever  been  known  to  possess  two  kinds  of  genital 
glands  both  showing  functional  activity.  It  is  extremely  doubtful 
whether  any  such  association  ever  will  be  demonstrated. 

Displacements  of  the  ovaries  are  of  frequent  occurrence.  They 
may  exist  in  any  degree  from  a  slight  descensus  to  a  complete  prolapsus, 
or  even  a  hernia. 

The  anatomical  connections  and  relations  of  the  ovary  render  it 
difficult  to  determine  the  precise  normal  locus  of  the  organ;  attached, 
as  it  is,  by  the  ovarian  ligament,  and  resting,  as  it  does,  on  the  fold 
of  the  broad  ligament,  it  enjoys  normally  a  considerable  range  of 
mobility.  This  seems  to  be  a  wise  provision  of  Nature  whereby  the 
sensitive  organ  is  enabled  to  evade  what  would  otherwise  be  painful 
pressure  from  neighbouring  structures,  such  as  the  uterus,  the  caecum, 
the  sigmoid,  and  even  the  overloaded  bladder.  The  ligamentum  ovarii 
proprium  is  firm  and  round,  consisting  of  fibro-muscular  elements,  is 
covered  by  peritoneum,  has  a  length  of  about  2.6  centimetres,  and  is 
essentially  inelastic;  while  the  duplicatures  of  peritoneum,  which 
comprise  the  remaining  suspensory  apparatus  of  the  ovary  and  permit 
that  organ  to  ascend  with  the  fundus  uteri  during  pregnancy,  are 
highly  elastic.  It  is  to  be  seen,  therefore,  that,  to  an  important 
extent,  the  position  of  the  uterus  determines  the  position  of  the 
ovary.  The  ovary  moves  with  the  uterus  and,  to  some  extent,  independ- 
ently of  it. 

Descensus  and  Prolapsus. — ^When  these  variations  of  position  occur, 
however,  they  do  not  involve  the  establishment  of  either  traction  or 
pressure  upon  the  organ  whereby  its  circulation  becomes  mechanically 
disturbed,  nor  is  the  ovary  prevented  from  returning  within  what 
may  be  recognised  as  its  normal  bounds  and  limits.  There  are  cases, 
however,  in  wbich  the  organ  is  forced  into  a  distinctly  abnormal  posi- 
tion. Thus,  it  is  occasionally  found  posterior  to  the  uterus  and  riding 
upon  the  utero-sacral  fold  of  the  peritoneum;  in  other  instances  it 
gravitates  into  the  cul-de-sac,  often  becoming  adherent  (Fig.  240); 
in  a  few  cases  it  has  been  found  adherent  between  the  uterus  and 


564 


A  TEXT-BOOK  OF  GYNECOLOGY 


the  bladder^,  while  in  still  other  cases  it  has  been  found  adherent  to 
the  intestines  and  drawn  by  them  well  above  the  brim  of  the  pelvis. 

Uterine   fibromata  are   frequent   causes   of   ovarian   displacement, 
the  organ  often  becoming  diseased  in  consequence  of  repeated  trau- 
matisms inflicted  by  the 
neoplasm. 

The  symptoms  of  pro- 
lapsus uteri  include  pain, 
which  is  generally  re- 
ferred to  the  normal 
locus  of  the  organ  with- 
out reference  to  its  dis- 
placed position;  and, 
generally,  nervous  re- 
flexes of  the  most  vague 
and  indefinite  character, 
with  a  tendency  to  in- 
crease in  complexity  and 
seriousness.  The  diag- 
nosis, however,  must  rest 
upon  careful  physical  ex- 
ploration, under  anses- 
thesia  if  necessary. 

The  treatment  should 
be  addressed  primarily  to 
any  recognised  causal 
condition;  thus,  in  the 
presence  of  a  retro-devia- 
tion of  the  uterus,  that 
condition  is  to  be  reme- 
died before  attention  is 
given  to  the  displace- 
ment of  the  ovary.  If  the  cure  of  the  causal  condition  does  not  re- 
sult in  relief  of  the  remaining  symptom  and  in  restitution  of  the 
ovary  to  its  normal  position,  surgical  treatment  should  be  addressed 
to  the  ovary  itself.  It  may  be  stated  as  a  rule  to  which  there  are 
but  few  exceptions,  that  an  ovary  which  has  acquired  the  habit  of 
descensus  can  be  made  to  remain  in  its  normal  position  only  by 
means  of  surgical  fixation.  This  may  be  done  in  many  cases  by  short- 
ening the  round  ligament  by  Alexander's,  or  preferably  by  Mann's, 
method.  If  the  latter  oi)eration  is  selected,  a  suture  may  easily  be 
passed  through  the  utero-ovarian  ligament,  by  which  the  ovary  may 
be  anchored  in  its  normal  position.  The  ovary  itself  should  not  be 
injured,  even  in  a  surgical  way,  unless  it  is  the  seat  of  disease. 

Hernia  of  the  ovary  is  of  occasional  occurrence;  it  may  exist  at 
birth,  or  it  may  develop  in  old  age;  and  it  generally  consists  in  a 
descent  of  the  organ  through  the  canal  of  ISTuck,  which  persists  in 


Fig.  24(J. — •' ...  It  gravitates  into  the  cul-de-sac,  often 
becoming  adherent." — Reed  (page  563). 


MALFORMATIONS   AND   DISPLACEMENTS   OP  THE  OVARIES     565 

many  cases.  It  is  encountered  clinically  as  an  inguinal  hernia.  Men- 
ciere  lias  reported  4  cases  of  hernia  of  the  ovary  occurring  in  children 
and  has  been  able  to  find  7  others  on  record.  All  11  were  inguinal, 
9  were  on  the  left,  and  2  on  the  right  side,  and  in  one  instance  the 
uterus,  as  well  as  both  tubes  and  ovaries,  lay  in  the  sac. 

Browne,  after  a  careful  study  of  hernia  of  the  ovary,  concluded 
that  the  condition  was  of  more  frequent  occurrence  than  was  gener- 
ally supposed.  He  attributes  congenital  hernia  of  the  ovary  chiefly 
to  arrest  of  development  during  intrauterine  life;  and  finds  that  it 
is  always  inguinal,  often  double,  and  when  single,  generally  on  the 
left  side.  The  formation  of  this  condition  is  favoured  by  the  persist- 
ence of  the  canal  of  ISTuck  and  by  the  size  and  shape  of  the  ovary, 
which  is  at  first  a  long  flat  body  with  its  apex  pointing  toward  the 
canal. 

The  fact  that,  at  birth,  the  ovaries  are  situated  above  the  ilio- 
pectineal  line,  and  descend  during  the  first  few  months  into  the  true 
pelvis,  is  also  recognised  as  a  contributory  causal  circumstance. 

Hernia  of  the  ovary  is  generally  associated  with  corresponding 
descent  of  the  Fallopian  tubes,  and,  as  in  Menciere's  case,  the  uterus, 
too,  may  be  found  in  the  sac.  Acquired  hernia,  on  the  other  hand, 
is  not  always  inguinal,  but  may  occur  through  any  ordinary  hernial 
opening.  The  condition  generally  occurs  with  pre-existing  intestinal 
or  omental  hernia.  The  condition  is  generally  unilateral,  occurring 
more  frequently  on  the  right  side.  Labour  and  the  postparturient  re- 
laxation of  the  tissues  are  recognised  as  the  chief  causes. 

The  symptoms  of  ovarian  hernia  may  be  confusing  from  the  fact 
that  omentum  or  intestine  may  be  present  in  the  sac.  In  the  con- 
genital form,  this  complication  is  less  likely  to  occur.  In  such  cases, 
the  hernia  exists  as  a  small  painful  nodule,  lying  at  the  orifice  of  the 
inguinal  canal.  In  consequence  of  the  contraction  of  the  tissues  after 
the  descent  of  the  organ,  the  hernia  is  generally  irreducible,  any  effort 
to  push  the  tumour  back  being  the  cause  of  extreme  and  depressing 
pain,  which  may  produce  symptoms  of  shock.  The  absence  of  crepitus 
in  the  tumour,  and  of  the  usual  reflex  intestinal  symptoms,  indicates 
that  the  bowel  is  not  involved  in  the  protrusion.  The  tumour  may, 
however,  be  the  seat  of  important  changes,  induced  either  by  strangula- 
tion, or  by  organic  degeneration  of  the  ovary.  In  the  acquired  form 
of  hernia,  the  intestine  and  omentum  are  more  liable  to  be  found  in 
the  hernial  sac,  which,  as  already  intimated,  does  not  always  protrude 
through  the  inguinal  canal.  One  of  the  most  perplexing  forms  of 
hernia  of  the  ovary  is  that  in  which  the  protrusion  occurs  through  the 
obturator  canal.  Von  Eogner  Gusenthal  describes  a  case  in  a  patient 
sixty-six  years  old.  There  were  symptoms  of  strangulation,  with  pain 
and  indistinct  gurgling,  but  no  distinct  tumour,  in  the  right  groin; 
femoral  hernia  was  diagnosticated.  On  operation,  the  crural  canal 
was  clear,  but  a  bulging  was  seen  under  the  pectineus  muscle.  The 
muscle  was  divided  and  the  sac  of  the  hernia,  in  a  gangrenous  condi- 


566  A   TEXT-BOOK  OP   GYNECOLOGY 

tion,  bulged  forward.     This  contained  the  right  ovary  and  tube,  and 
a  coil  of  intestine,  all  gangrenous. 

The  treatment  of  these  cases  consists  in  incising  the  hernial  sac  and 
extirpating  the  ovary,  which  will  generally  be  found  to  have  undergone 
such  morbid  changes  as  to  render  its  return  to  the  peritoneal  cavity 
unjustifiable.  In  infantile  cases,  however,  the  organ  may  be  saved 
in  many  instances.  In  11  cases  collected  by  Menciere,  cure  resulted 
in  10;  in  8  by  radical  operation,  in  2  by  reduction  and  bandaging. 


CHAPTEE  XXXVII 

INFECTIONS   AND   INFLAMMATIONS   OF   THE   OVARIES 

Classification:  Hypersemia;  acute  inflammation;  chronic  inflammation — Bacteria 
of  tlie  ovaries — Individual  infections:  Streptococcous  infection;  gonocoeeous 
infection ;  pneumocoecous  infection ;  Bacillus  eoli  communis  infection ;  un- 
usual bacterial  infections ;  tuberculosis. 

The  classification  and  description  of  the  inflammatory  lesions  of 

the  ovary  presents  many  difficulties,  because,  first,  of  a  confusing  nomen- 
clature; and,  secondly,  the  ovary  can  scarcely  be  said  to  stand  alone 
in  its  pathologic  lesions,  since  its  close  association  with  the  other  organs 
■of  the  pelvis,  anatomically  and  physiologically,  makes  its  lesions  in 
a  vast  majority  of  cases  only  a  part  of  a  pathological  picture. 

A  primary  statement  in  this  chapter  must  correspond  with  that  on 
inflammatory  lesions  of  the  Fallopian  tubes,  to  the  effect  that  all  in- 
flammatory lesions  of  the  ovary  are  due  to  bacterial  infections.  Only 
after  such  a  dogmatic  and  sweeping  statement  may  we  qualify  it  by 
saying  that  malpositions,  irritations,  strangulations  or  new  growths, 
may  produce  hypersemias  and  subsequent  changes  in  the  tissues,  which 
are  very  closely  related  to  those  changes  brought  about  by  a  long- 
continued  action  of  the  less  virulent  germs.  In  other  words,  the  class 
containing  the  cases  of  greatest  number  and  clinical  importance  is  the 
bacterial,  and  the  minor  class  is  that  which  depends  upon  mechanical 
causes. 

Hyperaemia  of  the  ovary  is  a  physiologic  condition  during  men- 
struation (see  Menstruation),  sexual  excitement,  and  pregnancy.  In 
this  connection,  however,  we  consider  only  those  hypergemias  which 
overstep  the  physiologic  limitations.  This  is  exemplified,  for  example, 
in  a  case  in  which  there  exists  a  malposition  of  the  ovary  with  twist 
of  the  mesovarium,  thus  interfering  with  the  venous  circulation;  it  is 
also  shown  in  the  case  of  prostitutes  who  are  subjected  to  excessive 
natural  or  unnatural  sexual  excitement;  also,  inflammation  in  other 
pelvic  organs  and  pressure  from  neighbouring  tumours  and  pessaries, 
are  among  the  recognised  causes  of  this  persistent  excess  of  blood  in 
the  ovary.  Bacterial  toxines,  or  the  germs  themselves,  may  induce  a 
hyperaemia  from  which  the  essential  phenomena  of  inflammation  are 
absent.  A  hypera;Tiii;i  of  iliis  class  is  easily  transformed  into  an  active 
infhirnmation   tlirongli    llu^    influence   of  infection   by   even   the   less 

5G7 


568  '       A   TEXT-BOOK   OF    GYNECOLOGY 

virulent  bacteria.  The  excessive  blood  supply  may  continue  to  in- 
crease, until,  by  sheer  force  of  mechanical  pressure,  there  occurs  transu- 
dation of  the  liquor  sanguinis  and  migration  of  the  leucocytes.  A 
hyperaemia  may  thus  become  transformed  into  an  inflammation.  The 
organization  of  the  transuded  elements  constitutes  a  true  hyperplasia, 
while,  as  a  result  of  the  persistent  excessive  nutrient  supply,  pre-exist- 
ing histologic  elements  may  become  enlarged,  thus  establishing  a  true 
hyiDertrophy.  In  any  event,  the  change  in  the  stroma  is  such  as  to 
render  it  unyielding  to  the  premenstrual  blood  pressure,  this  condition 
inducing  extreme  pain  during  the  few  days  preceding  the  onset  of  the 
monthly  flow.  A  passive  hypersemia  of  the  character  herein  described 
exhibits,  on  microscopic  examination,  dilated,  normal  vessels,  well 
filled  with  blood,  the  walls  of  the  blood  vessels  thickened,  and  some- 
times thrown  into  folds  which  project  into  the  lumen.  In  some  cases, 
the  walls  of  the  vessels  have  been  found  to  be  the  seat  of  hyaline 
degeneration.  In  other  cases,  however,  marked  perivascular  changes 
are  noted;  the  stroma  of  the  ovary  may  show  a  round-celled  infiltra- 
tion, and,  as  already  indicated,  a  decided  hyperplasia. 

The  walls  of  the  follicles  may  yield  to  the  blood  pressure,  the  fol- 
licles themselves  becoming  the  seat  of  slight  hemorrhages,  and  their 
walls,  when  cut  and  mounted,  giving  the  appearance  of  minute  punc- 
tate hemorrhages.  The  hypertrophic  changes  in  the  stroma  itself  may 
interfere  with  the  spontaneous  rupture  of  the  follicles,  which,  as  a 
result,  undergo  degeneration.  The  most  frequent  consequence  of 
hyperemia  of  the  ovary  is  that  form  of  hemorrhage  known  as  hema- 
toma.   (See  Hematoma  of  the  Ovary.) 

The  prognosis  of  hyperemia  of  the  ovary  is  favourable  in  its  early 
stages  and  before  it  has  resulted  in  marked  trophic  changes  in  the 
organ  itself.  When  these  changes  have  occurred,  however,  the  condi- 
tion becomes  essentially  progressive.  The  treatment  in  the  early  stages 
may  be  said  to  be  confined  to  efforts  to  remove  the  causative  condition; 
this  once  accomplished,  the  hypergemia  itself  will  subside.  In  the  later 
stages,  however,  when  the  ovary  has  become  the  seat  of  hyperplastic 
and  hypertrophic  changes,  and,  particularly,  when  the  follicles  have 
undergone  degeneration,  the  condition  is  irremediable  by  any  other 
means  than  ablation  of  the  organ.     (See  Oophorectomy.) 

Acute  inflammation  of  the  ovary  manifesting,  in  all  of  their  inten- 
sity, the  phenomena  of  vascular  engorgement,  circulatory  stasis,  tissue 
infiltration,  and  the  migration  of  corpuscles,  and  resulting  in  sup- 
puration, always  depends  upon  infection.  The  same  may  be  said  of 
those  inflammations  of  the  ovaries  that  do  not  result  in  the  destruction 
of  tissue — for  it  is  to  be  remembered  that  ovarian  tissue,  like  other 
tissues,  has  the  power  within  certain  limits  of  resisting  invasion  by 
micro-organisms,  although  the  defensive  effort  induced  by  the  presence 
of  the  germs  may  be  productive  of  all  the  essential  phenomena,  short 
of  suppuration  itself.  The  resulting  changes  in  the  tissues  may  be 
more  or  less  permanent,  manifesting  themselves  in  increased  density 


INFECTIONS  AND  INFLAMMATIONS  OF   THE   OVARIES        509 

of  the  stroma,  in  permanent  enlargement  of  previously  distended  blood 
vessels,  and  in  organization  of  the  inflammatory  products. 

Acute  oophoritis  is  usually  the  result  of  streptocoecous  infection. 
The  ovary  is  swollen,  soft,  and  of  elastic  consistence,  the  blood  vessels 
are  strongly  injected,  the  stroma  is  infiltrated  by  serum  and  pus,  and 
the  surface  of  the  organ  is  the  seat  of  a  general  peritonitis  which  is 
accompanied  by  a  deposit  of  fibrin,  a  pseudomembrane,  and  pus.  The 
stroma  is  filled  by  minute  abscesses,  and  is  indurated;  the  undeveloped 
follicles  are  highly  infiltrated  by  small  round  cells,  and  the  more 
mature  follicles  lose  their  epithelium  and  are  transformed  into  pus 
sacs.  The  sheaths  of  the  blood  vessels  are  infiltrated  by  small  round 
cells.  This  condition  may  continue,  to  the  complete  destruction  of 
the  ovarian  stroma  by  a  fusion  of  abscesses;  or,  with  the  subsidence 
of  the  inflammation,  the  ovary  may  return  to  its  normal  size,  but 
be  left  indurated  and  bound  down  by  adhesions,  and  rarely  retaining 
a  functional  value.  A  corpus  luteum  is  apt  to  serve  as  a  focus  of 
especial  activity  and  early  abscess  formation. 

The  gonorrhoeal  infections  may  undoubtedly  produce  an  acute 
oophoritis  (Wertheim,  Menge)  but  the  lesions  are  usually  confined  to  the 
surface  of  the  ovary.  Abundant  adhesions  are  formed.  The  follicular 
contents  become  turbid  and  almost  purulent,  or  they  may  be  blood- 
tinged.  There  is  an  infiltration  and  thickening  of  the  stroma  by  small 
round  cells — a  lesion  which  has  a  considerable  importance  in  the  ex- 
planation of  follicular  cyst  the  result  of  a  toughened  follicular  capsule. 

Chronic  inflammation  of  the  ovarian  tissue  manifests  itself  pri- 
marily in  a  proliferative  activity  in  the  stroma,  'which  leads  to  an  in- 
filtration by  small  round  cells  and  the  deposit  of  new  connective  tissue. 
The  blood  vessels  will  be  somewhat  dilated  and  their  sheaths  infil- 
trated by  small  round  cells.  The  parenchyma  or  G-raafian  follicle 
will  be  unchanged  in  the  early  forms,  but  the  gradually  increasing 
deposit  of  firm  fibrous  tissue  in  both  the  connective  tissue  and  muscular 
elements  of  the  stroma,  presses  on,  and  will  cut  off,  more  and  more, 
the  nutrition  of  the  follicle,  to  a  degree  of  destruction  which  may 
range  from  the  mildest  interference  to  a  complete  obliteration  of  all 
specific  ovarian  elements.  This  connective-tissue  change  may,  however, 
be  limited  to  the  surface  of  the  organ,  and,  even  though  the  Graafian 
follicle  persists,  it  is  rendered  functionless  by  the  complete  encasing 
shell  of  the  albuginea.  Such  ovaries  may  be  larger  than  normal,  cystic, 
and  presenting  a  smooth  surface;  or  the  interstitial  connective  tissue 
may  contract  after  its  formation  to  give  an  organ  which — smaller  than 
usual- — has  a  roughened  and  distorted  surface,  and  is  in  reality  a  dense, 
new,  interstitial  connective-tissue  ball.  In  the  latter  type  of  inflam- 
mation, the  Graafian  follicle  is  usually  entirely  absent,  and  the  arteries 
are  tortuous  and  have  much  thickened  walls.  In  those  types  which 
present  enlargement,  many  of  the  Graafian  follicles  are  transformed 
into  cysts  of  varying  size  and  the  vessels  are  widely  dilated,  especially 
the  veins. 


570  ^   TEXT-BOOK  OF  GYNECOLOGY 

Chronic  oophoritis  is  usually  preceded  by  an  acute  inflammation, 
but  may  gradually  develop  as  the  result  of  long-continued  mechanical 
irritation  or  obstruction  in  the  blood  flow.  The  morbid  changes  present 
a  variety  which  has  led  to  the  designation  of  several  classes  of  chronic 
ooi^horitis;  but  the  divisions  scarcely  seem  to  be  justified  on  a  com- 
23reliensive  study  of  chronic  inflammations  of  this  organ. 

Bacteria  of  the  Ovaries. — It  can  hardly  be  said  that,  as  yet,  there 
is  any  bacteriology  of  the  ovaries  as  distinct  from  the  facts  and 
considerations  already  brought  forward  in  reference  to  the  Fallopian 
tubes.  Yet  the  mode  of  entrance  and  the  resulting  pathologic  lesions 
vary  with  the  variety  of  germ  j)resent,  to  a  degree  that  makes  a  rather 
detailed  study  of  the  bacteria  concerned  in  ovarian  infections  necessary. 

The  anatomic  structure  of  the  ovary,  the  peculiar  physiologic 
activity  as  expressed  in  a  periodic  congestion  and  the  rupture  of  a 
Graafian  follicle,  the  liability  to  the  development  of  new  growth,  and 
the  tendency  to  torsion  of  the  ovarian  pedicle,  lay  the  ovary  open  to 
invasion  by  bacteria  in  a  way  from  which  even  the  tubes  are  to  some 
extent  free.  Furthermore,  we  must  class,  as  predisposing  causes, 
almost  every  inflammatory  condition  of  the  female  genital  tract,  a 
statement  given  its  greatest  force  by  a  mere  reference  to  the  ex- 
treme frequency  of  the  tubo-ovarian  abscess  in  gynecological  prac- 
tice, which  shows  that  the  tubes  and  ovaries  are  often  subject  to 
the  same  bacterial  ravages.  This  fact  is  further  borne  out  by  the 
statistics  of  Martin,  which  show  that  out  of  4,948  polyclinic  ovarian 
patients,  1,464  sufl:ered  from  subacute  or  chronic  endometritis,  and 
834  from  chronic  metritis.  Yet  another  causative  factor  is  found  in 
the  fact  that  when  new  growths  of  the  ovary,  belonging  to  the  class 
of  cystoma,  undergo  changes  such  as  result  from  torsion  of  the 
pedicle,  they  are  liable  to  the  inroads  of  the  Bacillus  coli  communis 
and  of  saprogenic  saprophytes,  from  adhesion  to  the  intestines.  Con- 
sidering our  theories  of  invasion,  it  must  be  held  to  be  a  remarkable 
thing  that  the  occurrence  of  abscess  in  a  cystic  ovarian  tumour  is  so 
rare,  yet,  follicular  abscess  the  result  of  bacterial  infection  is  much 
more  common.  This  fact  may  be  due  to  the  open  wound  produced  by 
the  rupture  of  a  follicle  giving  an  easy  entrance  into  the  ovarian  tissue 
to  the  pathogenic  organism,  thus  forming  a  point  of  departure  for 
further  inroads. 

The  modes  of  entrance  of  bacteria  to  the  ovary  are,  in  general,  iden- 
tical with  those  already  discussed  under  the  head  of  infections  of  the 
Fallopian  tube.  These  channels  are:  First,  the  lymphatics  and  blood 
vessels  which  establish  a  direct  line  of  transmission  from  the  external 
genitalia,  and  the  mucosa  of  the  vagina  and  uterus,  to  the  ovary.  (See 
Tuberculosis  of  the  Fallopian  Tubes.)  This  is  specified  as  the  channel 
of  preference  for  all  bacteria  except  the  gonococcus.  Secondly:  The 
female  genital  tube  connects  the  surface  of  the  ovary  with  the  external 
air,  and  any  infection  may  traverse  this  distance  from  the  surface  of 
the  body  (practically  from  the  vagina)  to  the  surface  of  the  ovary,  to 


INFECTIONS  AND  INFLAMMATIONS   OF   THE   OVARIES       571 


cause  an  inflammation.  This  is  siDecified  as  the  channel  of  preference 
for  the  gonococcus.  Thirdly:  It  has  been  clearly  demonstrated  that 
bacteria  may  pass  through  the  wall  of  the  intestine  (especially  at  a 
point  of  ulceration),  gravitate  to  the  pelvis,  and  cause  infection  of  the 
ovary  (Grrawitz,  Stoecklin),  or  that  bacteria  may  pass  from  the  intestines 
through  adhesions  which  bind  them  to  it.  This  will  be  specified  as  the 
channel  through  which  the  Bacillus  coli  communis  usually  passes. 

A  study  of  the  specific  characteristics  of  each  type  of  infection, 
and  their  relation  to  each  other,  will  be  best  carried  out  by  considering 
separately  the  most  important  of  the  bacteria  that  may  cause  ovarian 
disease.  Yet,  this  treatment  of  the  subject  is  only  possible  after  a 
very  positive  statement  already  made  (see  Fallopian  Tubes)  to  the  effect 
that  every  infection  in  the  genital  tract  is  a  mixed  infection. 

Individual  Infections  of  the  Ovaries. — Streptococcons  infection  of 
the  ovaries  is  of  frequent  occurrence.  These  bacteria  reach  the  ovaries 
through  the  avenues  of  the  lymphatics  and  blood  vessels,  by  which 
they  are  distributed  directly  to  the  parenchjana  and  inaugurate  their 
activities  by  the  development  of  small  miliary  abscesses.  A  section 
of  ovarian  stroma  will  show  a  small  abscess  cavity  the  pus  of  which 
abounds  in  streptococci,  and  the  surrounding  stroma  will  be  studded 
with  migrated  leucocytes  (Fig.  341).  Sooner  or  later,  small  segments  of 
ovarian  tissue  become  de- 
tached and  are  found  in 
the  pus  of  the  gradually 
enlarging  abscess  cavity. 
Such  detached  segments 
of  tissue  will  show  it  to 
be  studded  with  strepto- 
cocci (Fig.  242).  These 
abscesses  may  develop  at 
any  point  from  the  cen- 
tre to  the  circumference 
of  the  ovary,  even  in  its 
wall.  They  form  irregu- 
lar cavities,  and  are  con- 
sequently liable  to  be 
mistaken  for  purulent 
cysts.  In  many  cases, 
however,  there  is  no  dif- 
ficulty in  establishing 
their  real  character.  Sev- 
eral foci  of  suppuration  may  be  simultaneously  established,  resulting 
in  the  coalescence  of  their  cavities  and  the  consequent  development 
of  one  relatively  large  abscess.  An  ovary  that  is  the  seat  of  this  form 
of  infection  is  very  liable  to  become  adherent  to  its  neighbouring 
Fallopian  tube.  A  remnant  of  necrotic  partition  may  be  observed  in 
some  cases  between  coalescing  pus  cavities  (Fig.  243).    The  suppurat- 


Fig.  241.- 


-"  A  small  abscess  cavity,  the  pus  of  which 
abounds  in  streptococci." — Keed. 


572 


A  TEXT-BOOK   OP   GYNECOLOGY 


m 


ing  cavity  in  the  ovary,  however,  is  generally  separated  from  the 
purulent  accumulation  within  the  tube  by  a  barrier  of  formed  tissue, 
which  may  itself  be  the  field  of  more  or  less  diffuse  infection  by  the 

streptococcus,  and  luelt  down  to 
form  a  wide  communication  be- 
tween the  tubal  and  ovarian  ab- 
scess cavity.  A  streptococcous 
infection  of  the  ovary  may,  how- 
ever, result  in  abscess  of  that 
organ  to  its  complete  destruction, 
without  the  formation  of  pus  in 
the  tubes,  and  with  the  tissue 
between  the  two  entirely  intact 
(Fig.  244). 

In  studying  the  pathology  of 
infection  of  the  ovaries  by  the 
streptococcus,  it  is  important  to 
bear  in  mind  the  antecedent 
chain  of  morbid  events.  The  in- 
fection having  occurred  primarily 
through  some  traumatism  or 
abrasion  in  the  uterus,  generally 
in  connection  with  parturition  or 
the  puerperium,  the  micro-organ- 
isms may  manifest  their  activity  in  the  uterine  muscularis;  or  they  may 
find  their  way  through  the  lymphatics  into  the  surrounding  cellular  tis- 
sue; or  they  may  continue  their  journey  and  invade  the  adnexa.  The 
invasion  may  be  arrested  at  any  one  of  these  three  stages,  or  a  given  case 


'•.2--  M 


Fig.  242. — "  Detached  segments  of  tissue  will 
show  it  to  be  studded  with  streptococci." 
— Reed  (page  571). 


"  -■;;?;r:?4 


;/\>v-' 


:':;S>;-.V-.^i:!7,,^ 


v^^->^;^ 


■ 


V^f^    -v.- :'■•>>  >•';  :.:j^  {:^\;-/-:>i^i;<^  .;:■; 


l'-'^^')^" 


■^i^ 


Fig.  243. — "  A  remnant  of  necrotic  tissue  may  he  observed  in  some  cases  between  coalesci 
pus  cavities." — Keed  (page  571). 


ng 


INFECTIONS  AND  INFLAMMATIONS   OF    THE   OVARIES        573 


may  exemplify  all  three  of  the  stages,  and  this,  occasionally,  with  such 
rapidity,  that  they  may  appear  to  be  coincident.  The  virulence  of  the 
micro-organisms  and  the  susceptibility  of  the  patient  are  the  two  factors 
which  determine  the  clinical  conduct  of  the  infection  at  the  various 
stages  of  its  invasion. 
Thus,  an  infection  of  the 
uterine  wall  may  be  ar- 
rested, either  spontane- 
ously or  by  treatment, 
and  resolution  may  fol- 
low; or  active  suppura- 
tion may  develop.  A 
similar  infection  of  the 
circumuterine  tissues 
may  have  a  similarly 
variable  course  and  the 
same  may  be  true  of  the 
appendages.  The  inter- 
val between  either  of 
these  progressive  stages 
of  invasion  may  be  of 
variable  length.  It  thus 
happens  that  the  strepto- 
coccous  infection  of  the 
uterine  appendages  may 
develop  remotely  in 
point  of  time  from  the 
original  infection;  or  it 
may  be  practically  a  si- 
multaneous occurrence.  In  any  event,  the  history  of  the  case  and 
the  revelations  of  histological  examination  will  alike  shoAV  that  the  in- 
vasion has  taken  place  through  one  or  the  other,  or  both,  of  the  circula- 
tory media. 

It  is  entirely  apparent  that  the  ovarian  lesion  is  only  a  part  of  the 
clinical  picture  presented  by  such  a  streptococcous  infection.  The 
lesions  in  the  uterus  and  the  Fallopian  tubes  have  been  previously 
described;  yet  it  seems  desirable  to  call  attention  at  this  point  to 
the  severe  "  perioophoritis  "  that  occurs  in  these  cases.  A  variable 
degree  of  peritonitis  is  always  set  up  which  results  in  the  destruction 
of  the  peritoneum,  in  large  deposits  of  fibrin,  and  in  adhesions  that  bind 
down  the  ovary  to  surrounding  organs,  until  it  is  so  completely  covered 
in,  that  its  liberation  becomes  one  of  the  most  difficult  operations  of 
the  surgeon,  and  can  only  be  accomplished  by  actual  dissection,  which 
leaves  a  raw  cavity.  In  fact,  the  symptoms  from  which  the  patient 
suffers  after  the  subsidence  of  a  pelvic  peritonitis,  are  explained  almost 
wholly  by  this  perioophoritis  with  the  accompanying  adhesions.  In- 
deed, tliis  part  of  the  ovarian  lesion  has  led  to  a  distinct  classification 


Fig.  244. — "  A  streptococcous  infection  of  the  ovary  may 
result  m  abscess  of  that  organ  to  its  complete  de- 
struction."— Eeed  (page  572). 


574  A  TEXT-BOOK  OF  GYNECOLOGY 

by  some  authors  as  "  adherent  and  bound-down  ovaries,"  and  this  diag- 
nosis will  be  found  in  many  case  books  as  the  indication  for  operation. 

Gonococcous  infection  of  the  ovaries  is  of  relatively  the  most 
frequent  occurrence.  The  iniiammation  in  these  cases  manifests  itself 
primarily  upon  the  surface  of  the  organ.  This  is  accounted  for  by  the 
fact  that,  in  at  least  a  vast  majority  of  cases  if  not  in  all,  infec- 
tion of  the  upi^er  genitalia  by  the  gonococcus  occurs  by  the  progressive 
invasion  of  contiguous  mucous  surfaces.  In  this  wa}^,  the  infection 
travels  from  the  vagina  through  the  endometrium,  through  the  tubal 
mucosa,  until  it  reaches  the  surface  of  the  ovary.  Here,  it  becomes  the 
exciting  cause  of  an  inflammation  which  is  manifested  more  distinctly 
in  the  enveloj)ing  tunic  (perioophoritis),  than  in  the  deep  stroma  (par- 
enchymatous oophoritis).  Yet,  a  moment^s  reflection  upon  the  anat- 
omy will  show  that  the  division  of  the  inflammation  of  that  organ 
into  superficial  and  interstitial  can  not  be  justified,  as  neither  the 
cellular  nor  the  circulator}^  arrangement  of  the  ovary  will  permit  a 
definite  limitation  of  the  iniiammation  to  either  one  or  the  other 
structure.  It  is  a  fact  of  ordinary  observation,  however,  stoutly 
affirmed  by  Reymond,  that  the  gonococcus  attacks  the  surface  of  the 
ovary  and  is  never  demonstrable  in  the  pus  of  an  ovarian  abscess;  nor 
has  he  ever  seen  the  cyst  of  an  ovary  become  purulent  in  the  presence, 
or  in  consequence,  of  gonorrhoeal  salpingitis.  He  has,  however,  ob- 
served as  the  result  of  gonorrhoeal  contamination  of  the  surface  of  the 
ovary,  peripheral  sclerosis  and  the  formation  of  numerous  follicular 
cysts  beneath  the  sclerotic  envelope.  It  is  precisely  the  development 
of  this  sclerosis  in  the  peripheral  layer  of  the  ovary  that  prevents  the 
rupture,  and  causes  the  subsequent  degeneration,  of  the  gradually 
maturing  Graafian  follicles.     (See  Small  Cysts  of  the  Ovary.) 

It  must  be  further  stated,  however,  that  even  though  the  above 
represents  the  usual  conditions,  a  transmission  of  the  gonococcus  by 
contiguity  and  passage  through  the  tissues,  and  its  transfer  by  the 
blood  and  lymphatic  vessels,  are  not  only  possibilities,  but  are  held 
by  Luther  and  Wertheim  to  be  frequent.  A  mixed  infection  in  gonor- 
rhoea is,  perhaps,  the  rule,  and  any  reasoning  concerning  the  course  of 
the  transfer  must  be  qualified  by  this  possibility. 

The  inflammatory  reaction  of  the  neighbouring  peritoneum,  and 
the  production  of  adhesions  in  a  gonorrhoeal  inflammation  of  the 
ovaries,  will  be  very  similar  in  their  nature  to  the  processes  caused  by 
the  streptococcous  infection,  and  will  vary  with  both  the  intensity  of 
primary  infection  and  the  duration  of  its  action. 

Pneumococcous  infection  of  the  ovaries,  although  rare,  is  on  rec- 
ord. Von  Eosthorn,  Zweifel,  Frommel,  and  Witte,  have  each  reported 
cases  in  which  this  micro-organism  was  demonstrated  in  the  pus  of 
an  ovarian  abscess.  In  each  instance,  it  occurred  independently  of 
either  pneumonia  or  pulmonary  tuberculosis.  Microscopical  sections 
showed  the  abscess  Avail  to  contain  numerous  pneumococci,  mingled 
with  broken-down  tube  wall  and  ovarian  tissue.    Both  inoculation  and_ 


INFECTIONS  AND  INFLAMMATIONS  OF   THE  OVARIES        575 

tube  cultures  yielded  the  pure  micro-organism.  It  would  seem  that, 
in  its  manner  of  invasion,  and  in  its  effects  upon  the  ovarian  tissues, 
the  |)neuniococcus  differs  from  the  streptococcus  (see  Pneumococcous 
Infection  of  the  Fallopian  Tubes)  in  these  points,  viz.:  First,  it  may 
enter  by  way  of  the  general  circulation;  secondly,  there  is  a  remark- 
ably severe  invasion  of  the  jjeritoneum  as  shown  by  the  severe  adhe- 
sions; thirdly,  the  macroscopical  appearance  of  the  pus,  which  is  thick 
and  very  tenacious,  and  resembles  that  seen  in  empyema  following 
pneumonia  caused  by  the  Micrococcus  lanceolatus;  and  fourthly,  the 
fatal  cases  of  Frommel  and  Witte  speak  of  a  very  high  degree  of  viru- 
lence. 

Martin  suggests  the  possibility  of  a  diagnosis  in  the  absence  of  a 
history  of  labour  at  term  or  interrupted,  a  gonorrhceal  infection,  and 
in  the  presence  of  an  evident  severe  perimetritis. 

The  Bacillus  coll  communis  is  a  well-established  cause  of  ovarian 
abscess  in  a  small  percentage  of  cases.  It  is  a  significant  fact  in  con- 
nection with  the  mode  of  infection,  that  a  colon-bacillus  infection 
never  occurs  except  in  an  ovary  which  has  previously  been  adherent 
to  the  bowel.  It  would  be  rash  to  declare  that  the  other  channels  may 
not  serve  as  the  means  of  transfer  for  this  germ,  but  such  has  not 
been  observed.  The  bacteria  are  found  entirely  in  the  pus  and  on 
the  surface  of  the  abscess  wall.  The  main  characteristic  of  such  a 
bacterial  invasion  is  the  supervention  of  acute  constitutional  and  local 
symptoms  upon  a  previous  pelvic  inflammation. 

The  unusual  bacteria  found  in  ovarian  abscesses  are  actinomyces, 
described  by  Zemann;  the  bacillus  of  malignant  oedema  by  Witte  and 
others;  the  Bacillus  proteus  Zenkeri  by  Robb;  and  inoffensive  sapro- 
phytic bacteria  by  many  observers. 

Tuberculosis  of  the  Ovary. — Many  of  the  older  writers,  including 
Virchow  and  Rokitansky,  have  stated  that  tuberculous  oophoritis  is  of 
such  rare  occurrence,  even  if  it  ever  occurs,  that  its  consideration  is 
useless.  At  the  present  day,  however,  we  know  that  it  is  a  relatively 
frequent  disease  of  the  ovaries,  that  it  may  be  either  primary  or  second- 
ary, and  that  it  deserves  practical  attention  on  the  part  of  the  gyne- 
cologist. As  before  mentioned,  the  order  of  frequency  with  which 
tuberculous  disease  of  the  female  genital  organs  occurs  in  various  loca- 
tions is,  tubes,  uterus,  ovaries,  vagina,  cervix,  and  vulva.  Schottlander 
has  collected  153  cases  of  reported  tuberculous  oophoritis,  but  accepts 
only  30  of  these,  in  which  a  microscopic  examination  was  reported.  He 
admits  that  many  of  those  in  which  the  microscopic  examination  was 
not  made,  were  undoubtedly  tuberculous,  yet  thinks  they  can  not  have 
a  scientific  value.  It  is  only  since  the  advent  of  the  means  for  exact 
research,  and  the  cultivation  of  routine  methods  of  examining  all 
material  obtained  from  the  autopsy  table  or  the  operating  room,  that 
the  frequency  of  this  condition  has  been  demonstrated.  Such  methods 
have  nuule  it  clear  that  ovaries  showing  no  macroscopical  change  may 
yet  contain  nnniefous  miliary  tiibei'clcs  (Wolff,  Schottlander,  Franque). 


576  A   TEXT-BOOK   OF  GYNECOLOGY 

The  mode  of  infection  by  the  tubercle  bacillus  is  variously  ex- 
plained by  authors.  Klebs  believes  that  the  tube  is  the  usual  source  of 
infection,  and  that  the  infection  is  transmitted  in  continuity  of  tissue, 
rather  than  by  means  of  the  blood.  Others  believe  that  the  blood  is 
the  most  probable  carrier  of  the  tubercle  bacilli  (Mosler,  Guillemain), 
yet  Jani  and  Westermeyer-Jacksch  have  failed  to  find  the  tubercle  bacil- 
lus in  the  aj)parently  healthy  ovaries  of  a  series  of  phthisical  patients, 
and  the  latter  investigators  obtained  a  positive  result  in  only  one  case, 
by  the  inoculation  of  the  peritoneum  of  animals  by  such  ovaries. 
Schottlander  believes  that  the  peritoneum  is  the  usual  source  of  infec- 
tion, yet  accepts  a  tubal  origin,  and  believes  that  the  bacteria  may  often 
enter  by  an  abrasion  in  the  vagina  or  vulva,  and  ascend  to  the  ovary 
by  way  of  the  Ijonphatics  without  a  lesion  at  the  point  of  inoculation. 
Franque  has  directly  traced  such  an  infection  from  an  abrasion  in  the 
vault  of  the  vagina.  A  primary  localization  of  the  tubercle  bacillus  in 
the  ovary  is  extremely  rare.  Jacobs  has  reported  such  a  case  of  one- 
sided tuberculosis  of  the  ovary,  where  the  Fallopian  tube  showed  only 
an  interstitial  inflammation  and  the  lungs  were  certainly  only  in- 
volved after  the  operation.  Cases  in  which  the  process  is  primary  in 
the  genital  tract  are  not  so  rare  (Franque,  Schottlander,  and  others). 

Morbid  Anatomy. — The  anatomical  changes  characteristic  of  ovarian 
tuberculosis  are  the  formation,  in  the  majority  of  cases,  of  smaller  or 
larger  caseous  foci,  while  the  merely  miliary  form  is  seldom  met  with. 
Along  with  these  changes,  there  is  usually  present  in  the  organ  an 
inflammatory  condition  of  a  more  specific  character,  which  results  par- 
ticularly in  an  atrophying  process  in  the  follicle.  The  caseous  masses 
vary  in  size  from  that  of  a  millet  seed  to  that  of  a  marble,  may  run  to- 
gether to  form  apple-sized  cavities  in  which  almost  all  ovarian  tissue  is 
destroyed,  or,  as  has  occurred  in  certain  reported  cases,  the  ovarian  na- 
ture of  the  huge  abscess  cavity  may  be  difficult  of  demonstration.  Be- 
sides these  changes,  there  exists  a  simultaneous  adhesive  tuberculous 
pelviperitonitis  of  varying  degree.  Heiberg  has  often  found  a  forma- 
tion of  small  caseous  foci  in  the  dilated  follicle,  closely  resembling  a 
degenerated  rupture  follicle,  yet  the  process  seems  to  localize  by  prefer- 
ence in  the  stroma.  This  fact  has  been  demonstrated  as  the  rule  in 
the  collected  cases,  and  has  been  further  demonstrated  by  the  experi- 
ments of  Acconci,  in  which  the  injection  of  a  pure  culture  of  tubercle 
bacilli  into  the  ovary  always  resulted  in  an  interstitial  deposit  of 
tubercles,  but  never  so  when  into  the  follicle.  Schottlander  has  ob- 
served follicle  tuberculosis,  however,  in  rabbits. 

It  is  a  well-established  fact  that  a  miliary  tuberculosis  may  exist 
in  the  apparently  healthy  ovary  of  tuberculous  women  (Schottlander). 
H.  J.  'V\Tiitacre  has  observed  a  perfect  Graafian  follicle  in  the  midst  of 
ovarian  stroma  which  was  in  a  state  of  complete  tuberculous  infiltra- 
tion (Fig.  245).  The  miliary  tubercles  are  usually  found  in  the  super- 
ficial zone  of  the  ovarian  tissue,  but  sometimes  find  their  way  deeper, 
and  always  possess  the  usual  characteristics  of  epithelioid,  giant,  and 


INFECTIONS  AND   INFLAMMATIONS  OF   THE   OVARIES      577 


Fig.  245. — "  A  perfect  Graafian  follicle  in  the  midst 
of  ovarian  stroma  which  was  in  a  state  of  complete 
tuberculous  iuiiltratiou." — Whitacee  (page  576). 


round-celled  tubercles,  but  the  tubercle  bacilli  are  seldom  found. 
Wliitacre  and  Wolff  have  noted  the  appearance  of  considerable  num- 
bers of  very  large  giant  cells^  completely  alone  and  apart  from  other 
tuberculous  products,  in 
the  stroma  of  the  organ 
(Fig.  246).  Schottlander 
has  called  attention  to  the 
fact  that  the  normal  fol- 
licle, especially  when  cut 
just  to  one  side  of  the 
ovum,  will  give  rise  to  a 
collection  of  cells  that  very 
much  resemble  a  miliary 
tubercle.  The  same  confu- 
sion may  also  arise  from  an 
atrophied  follicle.  Frerichs 
has  further  stated  that 
caseous  foci  in  the  ovary  are 
not  necessarily  of  tuber- 
culous origin.     It  becomes 

apparent  that  this  confusing  feature  in  the  usual  histological  picture 
(Fig.  247)  of  tuberculosis,  when  associated  with  the  extreme  difficulty 
encountered  in  demonstrating  the  tubercle  bacillus,  will  render  even 

a    microscopic    diag- 
nosis difficult. 

The  symptoms  of 
the  disease  vary  with 
the  extent  of  the 
involvement  both  of 
the  ovary  and  of 
the  peritoneum.  The 
miliary  form  of  the 
disease  will  give  no 
symptoms,  while  the 
more  advanced  case- 
ous forms  may  give 
rise  to  the  most  se- 
vere symptoms  of 
pelvic  abscess. 

The   diagnosis  of 
the     condition     pos- 
sesses     a      scientific 
rather  than  a  practi- 
cal interest,  since  it  is 
impossible   to   recog- 
nise the  earlier  I  onus  by  any  known  means,  and  the  later  forms  are 
either  associated  vvitJi  disease  of  other  organs,  or  are  operated  on  under  a 
38 


Fig.  240. — "  Wliitacre  and  Wolff  liavc  noted  the  appearance 
of  very  large  giant  cells." — Wiiitaoke. 


578 


A  TEXT-BOOK  OF   GYNECOLOGY 


mistaken  diagnosis.  Martin  states  that  we  may  diagnosticate  a  tubercu- 
losis of  the  ovary  when  the  tube  end  is  not  enlarged  but  the  ovary  is 
represented  by  a  tumour  the  size  of  a  goose's  egg,  which  is  glued  to  the 
side  of  the  uterus  and  only  slightly  sensitive.  Hegar  considers  the  glu- 
ing of  the  tumour  to  the 
uterine  ligament,  as  in 
parametritis,  a  character- 
istic feature.  That  mis- 
takes can  be  made,  even 
in  the  microscopic  exami- 
nation, is  certain  (Mad- 
lener),  yet  the  appear- 
ance of  perfectly  typical 
miliary  tubercles  in  some 
part  of  the  structure  is  the 
rule,  and  the  regular  ar- 
rangement of  the  epithe- 
lial cells  of  a  follicle  with 
cement  substance  be- 
tween them,  will  usually 
serve  to  give  a  correct  di- 
agnosis. Again,  the  pres- 
ence of  giant  cells  does 
not  remove  every  diffi- 
culty of  diagnosis,  since 
an  egg  follicle  with  a 
moderately  thick  epithe- 
lial layer,  and  filled  by  granular  material,  my  resemble  greatly  the  giant 
cells  of  tuberculosis.  Yet,  in  giant  cells,  the  nuclei  are  less  regularly 
arranged  than  in  a  follicle,  and  the  long  axis  of  the  nucleus  is  tangential 
in  the  follicle  and  radial  in  the  giant  cell.  It  becomes  apparent  that  a 
thorough  microscopic  examination  is  an  unavoidable  necessity. 

Treatment. — The  treatment  of  ovarian  tuberculosis  will  be  almost 
exactly  that  of  the  tubal  type,  and  will  depend  upon  much  the  same 
reasoning  with  reference  to  the  general  condition  of  the  patient.  One 
of  the  unexplained  results  of  abdominal  surgery  is  the  almost  constant 
recovery  of  cases  of  tuberculous  peritonitis,  following  even  exploratory 
incision  of  the  abdominal  cavity.  These  cases,  even  when  associated 
with  extreme  ascites,  appear  to  undergo  resolution,  following  the  open- 
ing and  irrigation  of  the  peritoneal  cavity.  Eeed  has  cases  alive  and 
well  seven  years  after  operation,  the  peritoneum  at  the  time  of  opera- 
tion being  thoroughly  studded  with  tuberculous  deposits. 


Fig.  247. — "  The  usual  histological  picture  of  tuberculo- 
sis." a,  Graafian  follicles  ;  f>,  circumscribed  collection 
of  epithelioid  cells  containing  bodies  that  appear  to 
be  giant  cells ;  yet  this  is  not  a  miliary  tubercle,  but 
a  Graafian  follicle. — Whitacre  (page  577). 


CHAPTER  XXXVIII 

TREATMENT   OF  INFECTIONS   OF   THE   OVARIES 

Preliminary  considerations  —  Natural  terminations  —  Palliative  treatment  —  Con- 
servative treatment — Radical  treatment:  Oophorectomy,  indications;  unilat- 
eral— Effects:  Primary,  secondary. 

The  treatment  of  infections  of  the  ovaries  can  not  be  discussed  in- 
telligently without  taking  into  consideration  the  coincidence  of  similar 
infections  of  the  Fallopian  tubes  and,  frequently,  of  the  pelvic  lym- 
phatics. The  former  of  these  complications  has  already  been  dis- 
cussed (see  Infections  of  the  Fallopian  Tubes),  while  the  latter  will 
be  presented  in  a  subsequent  chapter.  (See  Infections  of  the  Pelvic 
Lymphatics.)  The  ovary,  however,  presents  special  points  for  con- 
sideration when  it  is  looked  upon  as  the  organ  of  ovulation,  and  when 
its  unique  morphology  is  taken  into  account.  Its  removal  or  complete 
organic  destruction,  when  occurring  on  both  sides,  implies  irremediable 
sterility,  the  exceptional  cases  of  fecundity  following  oophorectomy 
not  being  worthy  of  consideration  as  exceptions.  The  preservation 
of  the  ovaries  or  of  their  function,  in  all  cases  in  which  reproduction 
is  desirable,  is,  therefore,  a  matter  for  primary  consideration  after  the 
preservation  of  the  patient's  life  has  been  assured.  It  goes  without 
saying,  that  treatment  should  have  for  its  object  the  preservation  of 
these  organs,  when  this  can  be  accomplished  with  safety  to  the  patient's 
health  or  life.  When  surgical  intervention  should  take  place,  as  also 
its  extent,  must  be  determined  by  a  knowledge  of  the  natural  history 
of  the  morbid  changes  induced  by  infections. 

The  natural  termination  of  infections  of  the  ovaries  depends  largely 
upon  the  character  and  virulence  of  the  preponderating  micro-organism 
in  the  individual  case.  Streptococcous  and  pneumococcous  infections 
are  more  dangerous  to  life  than  those  depending  upon  the  gonococcus. 
The  primary  danger  to  life  from  these  infections  has,  probably,  been 
exaggerated.  This  fact  was  emphasized  by  Chrobak  {La  Semaine 
medicale),  who  stated  in  1893  that  the  statistics  of  the  Anatomico- 
Pathological  Institute  of  the  General  Hospital  of  Vienna  showed  that 
there  had  been  but  14-  deaths  from  inflammatory  diseases  of  the  uterine 
adnexa  in  about  42,000  cases  of  that  affection,  although  Schauta 
thought  that  they  were  of  more  frequent  occurrence,  since  he,  himself, 
had  seen  4  deaths  from  pyosalpinx  in  a  single  year.    It  is  highly  prob- 

579 


580  A  TEXT-BOOK  OF   GYNECOLOGY 

able  that  these  infections,  taken  as  they  come,  if  left  to  themselves 
would  yield  a  much  higher  mortality  than  that  indicated  by  either  of 
these  observers;  but  even  granting  this  to  be  true,  it  does  not  follow 
that  infection  of  the  appendages  is  the  uniform  menace  to  life  that 
is  ordinarily  supposed.  It  is  unfortunate  that  facts  are  not  at  hand 
upon  which  a  more  accurate  conclusion  could  be  based,  for,  upon  the 
determination  of  this  point  rests  the  justification  or  condemnation  of 
radical  intervention — particularly  in  the  presence  of  acute  inflamma- 
tions; but  both  Chrobak  and  Schauta  agree  that,  although  life  is  rarely 
compromised  by  these  diseases,  they  nevertheless  expose  the  patient 
to  the  most  serious  complications.  These  complications  vary  somewhat 
in  character  according  to  the  predominating  element  of  infection. 
Thus,  gonococcous  infection  presents  a  different  picture  from  that  de- 
pending upon  the  streptococcus. 

The  gonococcus,  which,  according  to  Reymond,  is  not  found  in 
the  pus  of  an  ovarian  abscess,  and  which,  according  to  all  observers, 
is  of  less  virulence  and  is  shorter-lived  in  the  peritoneal  cavity  than 
elsewhere,  produces  inflammation  that  is  manifested  with  relatively 
greater  virulence  on  the  surface  than  in  the  parenchyma  of  the  ovary. 
The  result  of  such  an  infection  is  to  produce  an  inflammatory  exudate 
on  the  surface  of  the  ovary  and  on  the  proximal  peritoneal  surfaces, 
resulting,  in  the  majority  of  cases,  in  adhesions  between  the  two.  It 
also  produces,  first,  thickening,  and,  subsequently,  sclerosis  of  the  in- 
vesting tunic.  As  a  result  of  these  changes  there  occurs  follicular 
degeneration.  (See  Morbid  Histology  of  Ovaritis.)  The  clinical  results 
of  these  changes  are  very  distressing  and  very  permanent.  An  ovary 
that  is  studded  with  unruptured  and  degenerated  follicles,  the  pressure 
of  which  has  resulted  in  the  atrophy  and  practical  disappearance  of 
the  stroma  of  the  organ,  is  functionally  useless.  An  ovary  which  is 
the  seat  of  these  changes  frequently  presents  to  the  sense  of  touch  a 
tension  greater  than  that  which  exists  in  the  eye.  It  can  readily  be 
understood  that  terminal  nerve  filaments  in  the  ovary  are  subjected, 
under  such  circumstances,  to  an  agonizing  pressure.  As  a  matter  of 
fact,  this  condition  is  the  most  painful  with  which  a  woman  can  be 
afflicted.  The  exacerbations  of  pain  incident  to  the  premenstrual  afflux 
of  blood  and  to  the  futile  efi'orts  at  ovulation,  are  agonizing  in  the  ex- 
treme. Patients  thus  afilicted  manifest  every  phase  of  the  so-called 
reflex  neuroses,  and,  not  infrequently,  are  the  victims  of  equally  dis- 
tressing psychoses.  Hysteria,  hystero-epilepsy,  and  their  congeners, 
are  sequela  of  frequent  occurrence;  while  constipation,  indigestion, 
self-intoxication  and  the  ana?mias,  are  frequent  elements  of  the  clinical 
picture.  Wliile  this  is  true,  it  must  be  recognised  that  there  are  cases, 
relatively  few,  perhaps,  in  which  there  appears  to  be  complete  recovery 
of  the  organ.  In  streptococcous  infection,  however,  the  invasion  takes 
place  directly  into  the  ovarian  stroma,  resulting  in  multiple  coalescing 
abscesses  and  the  consequent  destruction  of  more  or  less  of  the  ovary. 
As  elsewhere  pointed  out,  these  purulent  accumulations  may  become 


TREAT31ENT  OF  INFECTIOXS  OF  THE  OVARIES  5S1 

ven-  large  and  may  find  a  spontaneous  outlet  through  the  intestines, 
the  bladder,  or  the  pelvic  wall,  or  directly  into  the  peritoneal  cavity. 
Symptomatic  recovery  may  follow  any  one  of  the  three  former,  but 
death  is  the  usual  result  of  the  last-named  complication.  Suppura- 
tion of  the  ovan,-  involviag  a  considerable  destruction  of  the  stroma, 
may  be  di-aiued,  either  spontaneously,  or  by  operative  intervention, 
leaving  a  certain  amount  of  ovarian  tissue  which,  being  yet  studded 
with  primordial  cells,  may  subserve  the  function  of  ovulation.  But, 
unfortunately,  in  at  least  the  majority  of  these  cases,  suppuration  of 
the  stroma  is  associated  with  so  much  inflammation  of  a  peripheral 
character  that  adhesions  residt,  causing  essentially  the  same  painful 
and  intractable  conditions  as  have  already  been  described  as  the 
results  of  gonococcous  infection.  When  this  occurs,  there  become 
established  the  essential  underlying  causes  of  chronic  invalidism.  It 
follows,  therefore,  that,  viewed  in  the  light  of  their  natural  termina- 
tions, even  when  these  are  the  most  favourable,  infections  of  the  uterus 
demand  surgical  intervention,  generally  of  the  most  radical  kind.  It 
is  to  be  hoped  that  the  further  revelations  of  experimental  surgery 
may  develop  some  means  by  which  these  organs  may  be  either  con- 
served, or  replaced  by  stnictiires  with  functional  possibilities. 

Palliative  treatment  of  infections  of  the  ovary  must  be  considered 
with  reference  to  (a)  acute,  and  (&)  chronic  cases.  In  acute  inflamma- 
tions of  these  organs,  particularly  when  the  history  of  the  case  or  bac- 
teriological examination  of  it  points  to  infection  dy  the  gonococcus.  treat- 
ment should  be  based  upon  full  recognition  of  the  fact  that  these 
micro-organisms  in  the  peritoneal  cavity  are  of  diminished  virulence 
and  of  short  life.  The  inflammation  which  they  establish  may  be 
slight  or  severe,  according  to  the  susceptibilities  and  conduct  of  the 
patient.  3?hat  there  are  some  cases  that  react  with  greater  intensity 
than  others  to  inflammatory  influences  can  not  be  denied:  while  exercise, 
particularly  if  violent,  is  calculated  to  augment  an  inflammatory  pro- 
cess that  has  become  established.  The  indications  in  these  cases  are 
for  rest  and  elimination.  The  patient  shonld  be  put  to  bed  and  should 
be  given  a  saline  cathartic.  Opium  should  be  avoided,  and  anodynes, 
if  indicated,  should  consist  of  other  agents  of  recognised  value  which 
do  not  arrest  peristalsis.  The  hot  vaginal  douche,  with  glycerine  tam- 
pons in  the  interval,  should  be  employed  systematically  during  the 
first  four  or  five  days.  In  mild  cases  the  symptoms  will  disappear 
promptly  after  free  catharsis  induced  by  the  salines;  but  patients 
should  be  kept  in  bed  for  several  days  after  the  subsidence  of  the  pain. 
Ice-packs  over  the  groin  are  generally  of  more  value  than  applications 
of  the  opposite  extreme  of  temperature,  and  should  be  applied  from 
the  start.  In  streptococcous  infection  the  symptoms  are  generally  more 
active,  constitutional  intoxication  being  more  profound.  If,  in  a  given 
case,  the  symptoms  do  not  indicate  extreme  virulence,  the  palliative 
measures  already  indicated  may  be  relied  upon:  but  where  there  exists 
manifest  infection  of  the  uterus,  together  with  implication  of  the 


582  A   TEXT-BOOK   OF  GYNECOLOGY 

pelvic  lymphatics,  palliative  measures  beyond  those  elsewhere  discussed 
(see  Streptococcous  Infection  of  the  Uterus)  should  not  be  relied  upon. 
So  soon  as  the  enlargement  of  an  ovary,  with  associated  symptoms, 
indicates  the  presence  of  pus  in  that  organ,  surgical  intervention  is 
indicated. 

Pneumococcous  infection  comes  under  the  same  rule.  It  should  be 
stated  here  that  surgical  treatment  should  not  be  withheld  while  await- 
ing a  precise  diagnosis  of  the  character  of  the  infection,  but  should  be 
adopted  at  once  in  the  demonstrated  presence  of  pus. 

In  chronic  cases,  the  treatment  is  not  addressed  so  much  to  the 
infection  as  to  its  consequences.  As  a  matter  of  fact,  in  gonococcous 
infections,  which  comprise  the  majority  of  these  cases,  the  micro-organ- 
isms are  eliminated  as  active  factors  in  the  case  during  the  acute  stage. 
Under  these  circumstances,  and  in  the  absence  of  renewed  infection, 
that  which  is  generally  recognised  as  recurrent  inflammation  is  hyper- 
a?mia,  induced  mechanically  by  the  action  of  adhesions  or  by  the  pre- 
menstrual wave,  by  the  progressive  accumulation  of  unruptured  fol- 
licles, by  engorgement  of  the  portal  circulation  due  to  constipation,  or 
by  the  traumatisms  arising  either  from  accident,  or  from  sexual  inter- 
course. Eest,  laxatives,  douches,  and  tampons,  will  generally  relieve  the 
distressing  sjanptoms,  the  recurrence  of  which  may,  however,  be 
counted  upon  in  the  renewed  presence  of  the  same  exciting  causes. 

The  conservative  treatment  of  infections  of  the  ovaries  has  for  its 
object  the  perpetuation,  so  far  as  possible,  of  the  functions  of  these 
organs.  Whether  in  the  presence  of  acute  or  chronic  inflammation, 
treatment  should  be  addressed  to  preservation  of  the  organs,  whenever 
this  can  be  done  consistently  with  the  health  and  life  of  the  patient. 
It  would  seem,  as  an  abstract  proposition,  that  an  ovary  the  seat  of 
parenchymatous  suppuration,  should  no  more  be  extirpated  than  a 
finger,  the  seat  of  a  felon,  should  be  amputated.  Unfortunately  for 
this  hypothesis,  however,  the  morphology  of  the  ovary  is  such  that 
an  inflammation,  once  established  in  its  parenchyma,  generally  results 
in  its  functional,  if  not  its  organic  destruction.  (See  Morbid  Histology 
of  Ovaritis.)  Cases  have  been  reported  in  which  an  ovary,  the  seat 
of  suppuration,  has  been  brought  down  through  a  vaginal  incision, 
punctured,  the  pus  cavity  packed  with  gauze,  and  the  organ  returned 
to  the  pelvis,  with  the  result  of  complete  recovery.  The  fact  that 
an  organ  thus  inflamed  must  remain  inflamed  for  a  time  after  opera- 
tion, and  that,  during  such  persistence  of  inflammation,  it  is  liable 
to  develop  adhesions,  must  stand  as  a  barrier  to  the  success  of  this 
treatment  in  any  considerable  number  of  cases.  While  the  infection 
may  be  relieved,  the  consequences  of  the  inflammation  can  hardly  be 
averted.  In  chronic  cases,  in  which  the  surgeon  has  to  deal,  not  with 
the  infection,  but  with  its  consequences,  there  seems  to  be  a  better 
prospect  of  restoring  the  organ.  Eeed  has  repeatedly  excised  a  cyst 
or  cysts  of  the  ovary,  stitched  up  the  incision,  and  dropped  the  ovary 
back  (Fig.  348).    The  results  of  these  operations  have  not  always  been 


TREATMENT   OF   INFECTIONS  OF   THE   OVARIES 


583 


satisfactory,  and  no  guarantee  can  be  given  to  the  patient  that  she 
will  be  freed  from  pain.  On  the  contrary,  in  a  series  of  six  such  cases 
operated  upon  by  Reed,  all  the  patients  applied  for  the  radical  removal 
of  the  organ  before  the  expiration  of  three  months.  Schroder,  accord- 
ing to  A.  Martin,  was  the  first  to  attempt  to  remove  only  the  diseased 
portion  of  an  ovary, 
leaving  the  appar- 
ently healthy  part. 
Martin  adopted  this 
method  of  practice 
in  cases  of  adherent 
appendages  in  which 
the  patency  of  the 
tube  could  be  dem- 
onstrated, and  con- 
cluded (Volkmann's 
Sammlung  Minisclier 
Vortrdge)  that  the 
removal  of  the  dis- 
eased portions  of  the 
ovary  did  not  affect 
recovery  from  the 
operation;  that  exci- 
sion of  the  closed  or 
otherwise  diseased 
portion  of  the  tube 
did  not  affect  the 
healing  process;  that 
women  who  had  suf- 
fered such  partial 
removal  of  the  ad- 
nexa,  were  no  more 
liable  to  an  exten- 
sion of  the  disease  to 
the  healthy  portion 
of  the  resected  or- 
gans than  women 
whose  ovaries  were 
normal;  and,  finally, 
that     in     all     these 

cases  of  excision,  menstruation  persisted  and  conception  was  possible. 
Several  cases  of  pregnancy  have  begn  reported  following  the  adoption 
of  these  conservative  measures.  If  such  measures  are  contemplated  in 
a  given  case,  they  should  only  be  practised  with  the  knowledge  and  by 
the  consent  of  the  patient,  who  should  be  informed  frankly  of  the  lia- 
bility of  failure,  and  of  the  i)robable  necessity  of  subjecting  herself  to  a 
second  and  radical  operation  before  she  can  be  restored  to  health. 


HOthiNi;. 


Fig.  248. — "  Keed  has  repeatedly  excised  a  eyst  or  uysts  of 
the  ovary,  stitched  up  the  incision,  and  dropped  the  ovary 
back." — Eeed  (page  582). 


584:  A   TEXT-BOOK  OF   GYXECOLOGY 

The  radical  treatment  of  infections  of  the  ovaries  consists  in  the 
remoTal  of  the  diseased  organs.  As  the  Fallopian  tnhes  without  the 
ovaries  are  useless  structures,  and  as  they  are  generally  diseased  and 
can  be  removed  under  these  circumstances  without  embarrassing  the 
recovery  of  the  patient,  they  too  are  generally  removed. 

Oophorectomy  is  the  name  given  to  the  operation  for  removal  of 
the  un enlarged  ovaries;  it  is  also  known  as  Batte}^"s  operation,  and 
as  normal  ovariotomy.  It  was  first  performed  by  Dr.  Eobert  Battey, 
of  Eome,  Ga.,  on  the  ITth  of  August,  18T2,  for  the  purpose  of  caus- 
ing the  artificial  and  premature  occurrence  of  the  menopause  in  an 
otherwise  incurable  patient.  The  operation  succeeded  and  the  patient 
was  restored  to  health.  Battey,  during  the  remainder  of  his  life,  op- 
erated frequently  on  this  indication  and  with  remarkable  success.  His 
purpose  was  to  arrest  the  menstrual  molimen,  and  to  abolish  thereby 
a  painful  and  nervous  class  of  sj^mptonis  which  all  other  treatment  in 
his  hands  had  failed  to  cure.  "With  this  premature  and  forced  change 
of  life,  came  also  a  suspension,  and  finally  an  abolition,  of  the  class 
of  troublesome  symptoms  which  culminated  at  the  monthly  period. 
In  neurotic  patients  the}^  frequently  explode  in  violent  hysterical 
attacks,  while  in  aggravated  cases  insanity  has  sometimes  resulted. 

During  the  same  year,  February  11,  1872,  Lawson  Tait,  in  Eng- 
land, removed  the  ovaries  and  tubes  for  the  cure  of  chronic  inflamma- 
tions and  pus  collections  in  the  uterine  appendages,  and  Hegar,  in 
Germany  (July  27,  1872),  removed  the  ovaries  to  arrest  the  growth  of 
small  fibroid  tumours  of  the  uterus,  and  the  hemorrhages  caused  by 
their  presence.  Tait's  operation,  upon  what  are  now  known  as  "  pus 
tubes,"  is  referred  to  in  another  part  of  this  work.  (See  Infections  of 
the  Fallopian  Tubes.) 

Several  of  the  conditions  for  which  Battey  operated  are  now  relieved 
by  less  formidable  treatment.  The  wave  of  sacrificial  pelvic  surgery 
seems  to  be  passing,  and  a  conservative  tide,  having  for  its  object 
the  saving  of  one  ovary  and  part  of  the  other  if  possible,  is  rising. 
(See  Unilateral  Eemoval  of  Ovaries.)  The  sudden  and  stormy  onset 
of  the  change  of  life  is  thus  prevented,  and,  while  the  diseased  tissues 
have  been  resected,  enucleated,  or  otherwise  removed,  the  woman  does 
not  feel  unsexed,  as  she  calls  it,  and  "  so  totally  different  from  other 
women." 

The  operation  was,  for  a  time,  overdone.  Too  many  ovaries  were  re- 
moved by  youthful  inexperienced  operators.  The  pendulum  began 
gradually  to  swing  the  other  vraj,  till  now,  surgeons  hesitate  somewhat 
to  perform  oophorectomj^  even  in  the  few  cases  where  their  best  Judg- 
ment dictates  it  to  be  the  operation  best  suited  to  cure  their  patients. 

The  indications  for  oophorectom}^,  as  now  practised,  are  chiefly  in- 
fections of  the  ovaries;  inflammations  and  their  consequences;  certain 
rare  and  otherwise  incurable  cases  of  dysmenorrhoea;  certain  otherwise 
incurable  cases  of  ovarian  pain,  independent  of  the  periods,  and  mak- 
ing the  patient  an  incurable  invalid;   clear  cases  of  menstrual  epilepsy; 


TREATMENT   OF   INFECTIOXS   OF   THE   OVAFtlES  5S5 

menstrual  insanity,  when  the  attacks  occur  only  during  the  menstrual 
lA'eek,  the  patient  being  free  from  them  during  the  interral;  osteo- 
malacia; and  bleeding  uterine  fibromata,  of  small  size,  where  the 
patient  declines  hysterectomy  and  other  means  fail.  Eecently,  oopho- 
rectomy has  been  proposed  as  a  cure  for  mammary  cancer,  but  authentic 
reports  of  favourable  results  are  lacking  upon  which  to  found  an  in- 
dication. 

The  technique  of  the  operation  and  the  preparation  of  the  patient, 
the  surgeon,  the  nurses,  and  the  operating  room,  do  not  differ  materially 
from  that  of  any  median  abdominal  section  until  the  abdomen  is 
opened.  (See  Abdominal  Section.)  As  there  is  no  tumour,  the  in- 
cision need  not  be  more  than  2^  or  3  inches  long.  Two  fingers,  pref- 
erably^ of  the  left  hand,  are  passed  down  to  the  top  of  the  uterus  and 
out  along  the  tube  and  ovarian  ligament  to  the  ovar}-.  Any  adhesions 
are  gently  separated  and  the  ovary,  being  grasped  between  the  two 
fingers,  is  drawn  up  to  and  out  of  the  abdominal  opening.  The  tube 
should  be  well  dra\\Ti  up,  also,  and  the  pedicle  transfixed  as  near  the 
uterine  cornu  as  possible,  embracing  the  tube  in  its  sweep.  The  loop 
of  the  ligature  should  be  drawn  through  at  least  6  inches  and  cut, 
thus  making  two  ligatures,  one  being  tied  on  one  side,  and  one  on  the 
other,  of  the  included  tissues.  Should  any  doubt  exist  as  to  the 
security  of  the  constriction,  one  thread  may  be  carried  round  the  whole 
mass  in  the  groove  formed  by  previous  ligatures,  and  the  stump  thereby 
doubly  secured  against  any  subsequent  bleeding.  A  sufficient  button 
of  tissue  should  always  be  left  where  the  ovary  and  tube  are  cut  away, 
to  prevent  the  ligature  from  slipping  off  during  the  vomiting  and 
restlessness  of  the  patient  while  recovering  from  the  effects  of  the 
anaesthetic.  The  other  ovary  and  tube  are  found  in  the  same  way 
as  the  first,  brought  to  the  surface,  ligated,  and  cut  off. 

As  in  many  cases  the  aim  in  oophorectomy  is  to  arrest  menstruation 
with  all  that  it  implies,  great  care  should  be  exercised  in  such  cases 
to  remove  every  vestige  of  both  ovaries  and  tubes  down  to  as  near  the 
uterus  as  possible.  In  order  to  remove  the  nerve  supply  which,  it  is 
asserted  by  Arthur  W.  Johnstone,  of  Ciacinnati,  and  others,  presides 
over  the  menstrual  act,  some  surgeons  remove  a  V-shaped  piece  of  the 
uterine  cornu  and  stitch  together  the  sides  of  the  cavity  instead  of 
applying  the  regulation  ligatures  to  a  pedicle. 

There  is  rarely  any  loss  of  blood,  and  the  peritoneal  cavity  not 
having  been  soiled  in  any  way,  no  delay  is  necessary  to  complete  a 
"  toilet,"  and  the  abdominal  incision  is  closed  in  the  usual  way.  (See 
Abdominal  Section.)  The  operation  is  frequently  completed  by  an 
expert  g}Tiecological  surgeon  in  fifteen  minutes,  and  certainly  shoiild 
not  consume  more  than  half  an  hour  by  any  one. 

The  unilateral  removal  of  the  ovaries  or  of  the  uterine  appendages, 
leaving  t]ie  otlicr  and  apparently  healthy  appendages  in  situ,  remains 
one  of  the  moot  questions  of  surger}^  and  one  which  presses  itself  for 
consideration  in  connection  with  conservative  measures.    The  removal 


586  "A  TEXT-BOOK  OF  GYNECOLOGY 

of  any  organ  not  already  the  seat  of  disease,  is  against  the  instincts 
and  impulses  of  surgery;  and,  yet,  the  frequency  with  which  the  re- 
maining and  apparently  healthy  ovary  has  become  diseased  in  patients 
from  whom  the  other  and  infected  ovary  has  been  removed,  has  raised 
the  question  as  to  the  expediency  of  removing  both  organs  at  the  first 
operation.  In  approaching  a  decision  of  this  question,  it  is  to  be  re- 
membered again  that  the  majority  of  all  these  infections  are  gonor- 
rhoeal  in  character;  that  an  infection  may  travel  up  the  uterus  and 
out  through  the  tube  on  one  side,  before  passing  up  and  out  through 
the  tube  on  the  other  side;  and  that  a  remaining  ovary  is,  therefore, 
liable  to  inflammation  caused  by  the  later  extension  of  the  infection 
through  the  Fallopian  tube  of  that  side.  On  this  point  we  may  well 
accept  the  observations  of  Lawson  Tait  {American  Journal  of  Obstetrics, 
1887),  as  follows:  "Actuated  by  the  sound  principle  that  no  organ 
should  be  removed  which  is  not  diseased,  in  all  the  cases  of  the  varie- 
ties of  chronic,  inflammatory,  mischief  in  the  uterine  appendages, 
which  have  come  under  my  care,  I  have  not,  in  a  single  instance, 
removed  the  second  set  of  appendages  when  they  have  been  ascer- 
tained to  be  healthy.  ...  I  have  been  made  painfully  familiar  with  the 
frequency  with  which  operations  of  this  kind  have  proved  absolutely 
useless  for  the  purposes  of  the  operation,  and  where  the  disease  has 
recurred  in  the  other  side  and  demanded  a  second  surgical  interference. 
.  .  .  But  the  opinion  which  I  have  formed  ...  is  that  if  a  patient  is 
suffering  sufficiently  to  justify  an  abdominal  section  for  chronic  in- 
flammatory disease  of  the  uterine  appendages,  and  only  one  side  is 
found  to  be  affected,  the  operation,  to  be  of  that  lasting  and  complete 
benefit  to  the  patient  which  we  desire  all  our  operations  should  have, 
must  be  made  bilateral.  On  such  a  point  as  this,  of  course,  the  desire 
of  the  patient  must  be  paramount  as  upon  most  others,  and  if  a  patient 
placed  herself  under  my  care  for  such  an  operation,  and  made  it  an 
imperative  condition  that  I  should  not,  under  any  circumstances,  re- 
move the  second  set  of  appendages  if  they  were  found  healthy,  I 
should  yield  to  her  decision;  but  I  should  argue  the  question  with 
her,  and  advise  her  not  to  subject  herself  to  the  risks  of  a  second 
operation,  as  seems  to  be  by  far  the  greater  tendency  in  unilateral 
operations." 

The  effects  of  removing  the  ovaries  must  be  considered  with  refer- 
ence to  their  (a)  primary  and  (6)  secondary  effects. 

Primary  effects  take  into  consideration  the  mere  question  of  sur- 
gical recovery — the  healing  of  the  wound,  and  the  getting  up  of  the 
patient.  The  question  of  mortality  from  the  operation  has  established 
the  safety  of  the  procedure.  Numerous  operators  have  had  long  series 
of  cases  without  a  death.  Tait  once  reported  a  series  of  139  consecu- 
tive operations,  the  majority  of  them  involving  the  removal  of  the 
ovary,  without  a  death.  The  mortality  from  the  operation  should  be 
studied  with  reference  to  (a)  the  character  of  the  infection;  (b)  the 
constitutional  state  of  the  patient  at  the  time  of  operation;    (c)  the 


TREATMENT  OF  INFECTIONS  OF   THE   OVARIES  587 

environment  of  the  patient;  and  (d)  the  technique  adopted.  It  may 
be  stated  without  hesitancy  that  cases  of  streptococcous  infection, 
whether  operated  upon  early  or  late,  yield  the  largest  percentage  of 
deaths.  Eecent  acute  infections  in  which  the  pus  is  yet  virulent,  are 
more  dangerous  subjects  for  operation  than  those  in  which  the  micro- 
organism has  reached  its  vital  limitation.  This  latter  remark,  how- 
ever, must  not  be  accepted  as  a  reason  for  permitting  the  pus  of  active 
and  virulent  infection  to  become  innocuous  before  operation,  for  such 
delay  without  constant  observation  is  fraught  with  extreme  hazard  to 
the  patient — a  hazard  greater  than  that  of  operation.  This  leads  natu- 
rally to  a  consideration  of  the  constitutional  state  of  the  patient  at  the 
time  of  operation.  Oophorectomy  done  in  the  presence  of  an  acute 
constitutional  sepsis  is  always  attended  with  a  high  mortality;  and  yet 
the  majority  of  these  cases  can  be  said  to  have  no  prospect  of  recovery 
at  all  without  operation.  It  is  in  these  cases  of  acute  virulent  infec- 
tion with  more  or  less  pronounced  constitutional  intoxication,  that  the 
conservative  measure  of  tentative  puncture  and  drainage  should  be 
practised.  (See  Vaginal  Drainage.)  The  surroundings  of  the  patient 
have  much  to  do  with  her  recovery.  Nothing  is  more  clearly  demon- 
strated than  the  great  advantage  of  a  well-appointed  and  properly  con- 
ducted hospital  in  the  management  of  these  cases;  and  it  may  be  said 
with  equal  force  that  a  poorly  conducted  and  an  improperly  constructed 
hospital  is  more  dangerous  to  the  patient  than  any  other  possible  sur- 
rounding. The  mortality  from  abdominal  section  in  cases  of  this  class, 
may  be  conservatively  placed  at  from  15  to  20  per  cent  when  done 
either  in  poor  hospitals  or  in  no  hospitals,  and  at  less  than  5  per  cent 
when  done  in  well-appointed  and  well-conducted  institutions.  The 
question  of  technique  can  not  be  discussed  without  taking  into  con- 
sideration the  more  personal  element  in  the  equation  presented  by  the 
operator  himself.  It  goes  without  saying  that  these  operations,  to  be 
most  highly  successful,  must  be  done  with  the  greatest  skill,  and  that 
skill  can  not  be  expected  except  as  the  result  of  training  and  experi- 
ence on  the  part  of  the  operator.  The  lives  that  are  constantly  sacri- 
ficed by  untrained  men  who  simply  wish  to  try  their  hand  at  abdominal 
surgery,  would  fill  a  scarlet  book  of  horrors. 

The  secondary,  or  remote,  results  should  be  considered  with  refer- 
ence to  {a)  menstruation;  (&)  the  sexual  function,  including  repro- 
duction; (c)  the  menopause;  {d)  the  intrapelvic  state;  and  (e)  the  gen- 
eral constitutional  condition. 

Menstruation  is  arrested  in  the  majority  of  patients  from  whom 
both  ovaries  have  been  removed.  Pfister  studied  179  cases  operated 
upon  by  Kuhne,  between  1880  and  1896,  and  collected  statistics  from 
various  other  sources.  He  found,  on  a  basis  of  715  cases,  that  men- 
struation ceased  in  87.5  per  cent,  the  percentages  of  cessation  in  the 
various  lists  varying  from  75.6  to  97.3  respectively.  In  a  majority  of 
cases  there  occurs  a  sort  of  post-operative  metrostaxis,  which  may 
recur  a  few  times  after  intervals  of  varying  length,  but  this  is  not 


588  '        A   TEXT-BOOK  OF   GYNECOLOGY 

to  be  looked  upon  as  normal  menstniation.  A  few  patients  menstruate 
during  the  first  few  months  following  complete  extirpation  of  the 
ovaries  and  then  cease.  The  reasons  for  the  perpetuation  of  menstrua- 
tion in  the  12.5  per  cent  of  Pfister's  cases — and  they  are  alluded  to 
only  because  they  may  be  accepted  as  an  index  of  cases  in  general — are 
not  given^  and  in  the  nature  of  things  are  not  ascertainable.  The 
fact,  however,  that  in  many  cases  of  oophorectomy  it  is  necessary  to 
leave  a  small  segment  of  ovarian  tissue  in  situ  for  the  purpose  of  main- 
taining the  ligature  in  position,  and  the  fact  that  a  similar  segment 
is  frequently  left  through  carelessness  in  excising  the  ligatured  ap- 
pendages, will  probably  explain  the  majority  of  continuances  of  men- 
struation. It  is  known  that  in  many  cases  in  which  more  or  less  ovarian 
tissue  is  left  designedly,  the  menstrual  function  persists.  Bantock, 
Eeed,  and  numerous  other  operators  have  reported  cases  of  the  long 
persistence  of  menstruation  after  both  ovaries  were  known  to  have  been 
completely  removed.  Gonzalez,  of  Diriamba,  Nicaragua,  reports  (N^ew 
TorJc  Medical  Journal)  an  interesting  case  of  persistent  menstruation 
following,  not  only  the  complete  removal  of  both  ovaries,  but  of  the 
uterus  also. 

The  sexual  function  as  influenced  by  oophorectomy,  should  be 
discussed  with  reference  to  (a)  genital  sensation,  and  (h)  reproduction. 
With  reference  to  the  genital  sensation,  including  libido  sexualis,  it 
should  be  understood  at  the  start,  that  neither  is  as  uniformly  existent 
among  women  as  among  men.  Eelative  to  this  question  Lawson  Tait 
observed,  that  Avhen  it  is  "  carefully  inquired  into,  and  without  j)reju- 
dice,  it  is  found  that  women  have  their  sexual  appetites  far  less  de- 
veloped than  men,  a  fact  explained  by  the  process,  necessary  in  evolu- 
tion, that  the  male  has  always  been  the  struggling  and  aggressive 
creature.  When  the  child-bearing  period  of  a  woman's  life  jDasses  away, 
there  goes  with  it  a  certain  amount  of  her  sexual  ajDpetite.  In  a  few 
cases  the  appetite  entirely  disappears,  but  in  an  equally  large  number 
of  instances  it  becomes  exaggerated,  sometimes  grotesquely  so.  In 
the  majority  of  women  the  appetite  lessens,  and  even  disappears,  during 
the  time  of  the  climacteric  disturbance,  and  then  returns  to  its  former 
condition,  when  the  change  has  been  effected."  The  sexual  appetite 
in  its  relation  to  oophorectomy,  conforms  to  this  law,  and  can  not, 
therefore,  be  said  to  be  unhealthfully  modified.  This  theoretical  view 
of  the  case  seems  to  be  supported  by  an  investigation  of  the  actual 
facts.  Pfister  reports  upon  99  women,  in  19  of  whom  the  desire 
remained  normal;  in  2-4  it  seemed  somewhat  diminished;  in  35,  in 
many  of  whom  it  had  never  been  strongly  developed,  it  was  extin- 
guished, while  in  21  it  had  never  been  present.  Women  have  con- 
ceived after  the  extirpation  of  both  ovaries,  and,  for  that  matter,  of 
both  Fallopian  tubes.  Cases  of  this  kind  have  been  reported  by  Sippel 
(British  Medical  Journal),  Sutton  (Transactions  of  the  American  Gyne- 
cological Society)  and  Dunn  (Annals  of  Gynecolor/y  and  Pediatry).  These 
cases  are  distinctly  exceptional,  and  point  to  the  fact  that  an  ovule  pre- 


TREATMENT   OF   INFECTIONS  OF  THE   OVARIES  589 

viously  evolved  may  remain  for  a  considerable  time  and  retain  its 
vitality  in  the  folds  of  either  the  uterine  ostium  of  the  tube,  or  of  the 
endometrium. 

The  menopause  is  generally  precipitated  with  abruptness  following 
the  removal  of  the  ovaries.  The  patients  complain,  from  the  very  start, 
of  hot  flushes,  and  there  is  a  constant  sensation  of  temperature  vacillat- 
ing between  heat  and  cold.  The  face  burns,  even  without  a  correspond- 
ing turgescence  of  the  cutaneous  capillaries,  although  there  do  occur,  to 
a  certain  extent,  repeated  changes  from  florid  to  pale.  Associated  with 
these  phenomena  are  the  more  or  less  evanescent,  but  none  the  less 
distressing,  nerve  storms  incident  to  the  climacterium.  (See  The  Meno- 
pause.) It  can  not  be  said  that  these  phenomena  differ  in  quality 
from  those  of  the  natural  menopause,  although  they  generally  occur 
with  more  precipitation  and  greater  violence.  In  some  patients,  how- 
ever, they  are  but  little  noticed,  and  in  all  cases  they  disappear  in 
from  twelve  to  twenty-four  months.  It  is  the  distressing  character 
of  these  symptoms,  in  certain  cases,  that  has  prompted  surgeons  to 
attempt  the  mitigation  of  their  severity  by  leaving  in  position  a  part 
or  all  of  an  ovary,  even  after  the  removal  of  the  uterus  and  Fallopian 
tubes.  Satisfactory  reports  have  been  offered  by  Bland  Sutton  and 
others,  and  it  is  probable  that  the  practice  will  find  increasing  favour 
with  operators. 

The  general  system  is  influenced  within  certain  limits  by  removal 
of  the  ovaries.  In  these  cases,  there  occurs  to  a  certain  extent  an 
exemplification  of  the  law  of  antagonism  between  growth  and  genesis. 
When  growth  is  active,  the  reproductive  function  is  in  abeyance;  when, 
in  turn,  the  reproductive  function  ceases,  growth  again  attains  its 
normal  limit.  This  is  shown  in  the  increasing  rotundity  of  figure  fol- 
lowing the  normal  menopause.  The  same  tendency  exists  when  the 
change  of  life  is  induced,  artificially,  by  oophorectomy.  In  Pfister's 
table,  52  per  cent  of  the  collected  cases  showed  a  tendency  to  increase 
in  flesh;  in  30  per  cent  the  weight  remained  the  same;  while  nothing 
is  said  about  the  remaining  18  per  cent.  With  regard  to  those  who 
increased  in  flesh,  it  is  to  be  remembered  that  they  were  reduced  by 
disease  preceding  the  operation,  and  that,  in  many  instances  observable 
in  the  j)ractice  of  all  operators,  the  increase  of  flesh  amounts  to  noth- 
ing but  the  resumption  of  the  normal  standard.  Pfister  by  his  inves- 
tigations collected  accurate  data  by  which  to  refute  many  prevailing 
notions  about  the  constitutional  effects  of  oophorectomy — notions 
the  fallacy  of  which  have  been  known  to  operators  for  decades.  The 
vulgar  idea  that  women  who  have  lost  their  ovaries  become  gross  and 
masculine,  acquire  bass  voices  and  raise  whiskers,  is  only  an  indica- 
tion of  popular  ignorance  which  occasionally  finds  expression  by  an 
asinine  physician.  The  effect  of  removal  of  the  ovaries  upon  general 
metabolism  has  been  a  subject  of  inquiry,  which  has  been  given  a 
fresh  impetus  by  the  investigations  of  Curatullo  and  Tarulli  (Annali 
di  Osielricia  e  Oinecohgia),  investigations  obviously  undertaken  for  the 


590  '         -^   TEXT-BOOK  OF   GYNECOLOGY 

purpose  of  establishing  the  existence  of  what  they  designated  an  in- 
ternal secretion  of  the  ovary.  In  a  series  of  observations  on  previously 
castrated  lower  animals,  they  observed  variations  in  the  elimination  of 
metabolic  products;  while  in  osteomalacia  they  assumed  to  find  a 
clinical  confirmation  of  the  theory  that  the  ovaries  secreted  something 
which  could  not  be  found,  but  which,  nevertheless,  exercised  an  im- 
portant influence  over  tissue  change.  They  found,  in  brief,  that 
ablation  of  the  ovaries  modified  metabolism,  increased  phosphates  in 
the  urine,  changed  the  nitrogen  curve  either  up  or  down,  diminished 
the  elimination  of  carbonic  acid  and  the  absorption  of  oxygen,  and 
increased  the  weight.  In  applying  their  doctrine  to  women  they  failed, 
however,  to  take  into  account  that  every  fact  which  they  had  noted  was 
consistent  with  a  retvirn  to  the  normal  equilibrium  of  nutrition.  They 
mentioned  that  the  injection  of  ovarian  juice  caused  an  increased  elimi- 
nation of  phosphates,  proportionate  to  the  amount  injected,  but  they 
failed  to  take  into  account  the  fact,  that  a  similar  elimination  of  phos- 
phates occurred  following  the  similar  injection  of  like  foreign  ele- 
ments into  the  circulation.  They  assumed  that  this  element,  whatever 
it  was,  favoured  the  oxidation  of  phosphates,  and  they  called  attention 
to  the  point  that,  after  removal  of  the  ovaries,  or  before  or  after 
puberty,  there  should  be  an  increase  of  calcareous  salts  in  the  bones, 
the  deposition  of  the  latter  being  determined  by  the  action  of  the 
ovarian  juice.  It  is  unfortunate  for  this  theory  that,  in  the  natural 
course  of  events,  ovarian  quiescence  before  puberty  is  associated  with 
a  minimum,  while  ovarian  quiescence  after  the  menopause  is  asso- 
ciated with  a  maximum,  of  lime  salts  in  the  bones.  If  the  position 
of  these  investigators  were  tenable,  it  would  follow  that  the  condi- 
tion of  the  bones  before  puberty  and  after  the  menopause  would  be 
the  same.  Eclating  to  this  subject,  it  is  interesting  to  note  that  Heyse 
(Archiv  fiir  Gynakologie),  from  a  careful  microscopic  study  of  ovaries 
removed  from  osteomalacic  subjects,  decides  that  there  is  no  reason 
to  infer  that  there  is  any  diminution  in  the  number  of  primordial  cells 
under  these  circumstances,  and  consequently  that  there  is  no  ground 
upon  which  to  predicate  a  variation  in  the  so-called  "  internal  secre- 
tion." 

Intrapelvic  morbid  conditions  are  always  modified,  if  not  always 
cured,  by  the  ablation  of  the  appendages.  The  restoration  of  other- 
wise hopeless  invalids  to  symptomatic  health,  is  the  crowning  triumph 
of  this  operation  in  the  great  majority  of  cases.  Many  women  after 
passing  through  this  operation,  and  through  the  neurotic  disturb- 
ances of  the  artificial  menopause,  are  freed  from  pelvic  pain  and  are 
otherwise  healthy.  There  are  cases,  however,  and  a  number  of  them, 
in  which  the  removal  of  the  ovaries,  whether  for  acute  infection, 
chronic  inflammation,  or  cystic  degeneration,  is  not  followed  by  com- 
plete cure,  or  even  pronounced  amelioration,  of  the  pre-existing  intra- 
pelvic pain.  In  some  of  these  cases  the  painful  symptoms  subside  only 
after  the  lapse  of  one  or  two  years.     The  reason  for  this  delay  in 


TREATMENT   OP   INFECTIONS   OP  THE   OVARIES  591 

recovery,  or  failure  to  recover  at  all,  as  the  case  may  be,  is  to  be  found 
in  the  inflammatory  changes  which  have  become  established  outside 
the  adnexa.  Subserous  exudates  causing  pressure  on  filaments  of  the 
sacral  plexus,  and  organized  inflammatory  products  in  the  parenchyma 
of  the  uterus  causing  pressure  on  terminal  nerve  twigs  in  that  organ, 
are,  for  the  most  part,  accountable  for  this  persistence  of  pain.  In- 
flammatory changes  of  a  more  or  less  permanent  character  in  the  nerve 
sheaths  themselves  are  to  be  taken  into  account  in  this  connection. 
A  well-established  uterine  sclerosis  of  inflammatory  origin  is  a  per- 
petually painful  condition.  It  is  for  this  reason  that  the  French  school 
inaugurated  the  practice  of  removing  the  uterus  with  the  adnexa  for 
the  relief  of  otherwise  incurable  infectious  inflammations.  (See 
Doyen's  Operation  and  Panhysterectomy  under  Treatment  of  Infec- 
tions of  the  Fallopian  Tubes.) 


CHAPTER    XXXIX 
TROPHIC  DISEASES  OF  THE  OVARIES 

Atrophy — Cirrhosis — Hypertrophy. 

Atrophy  of  the  Ovaries. — Atrophy  of  the  ovaries,  a  physiologic 
change  at  the  climacteric,  becomes  pathologic  when  it  occurs  in  women 
during  the  period  of  sexual  activity.  This  variety  is  to  be  carefully 
distinguished  from  so-called  cirrhosis,  the  result  of  disease.  More- 
over, it  should  not  be  confounded  with  nondevelopment  of  the  gland 
in  women  who  have  never  menstruated. 

Causes. — In  a  well-recognised  class  of  cases,  Coe  observes  that  the 
rapid  development  of  obesity  in  young  women  is  associated  with 
scanty  menstruation,  which  may  eventually  cease  entirely.  Since  the 
uterus  is  normal  in  these  subjects,  there  is  little  doubt  that  the  ova- 
rian function  ceases  in  consequence  of  follicular  atrophy,  though 
opportunities  for  studying  this  condition  anatomically  are  rare.  Coe 
has  had  a  chance  to  verify  his  opinion  at  the  operating  table  in  a 
typical  case.  The  intimate  relation  between  the  ovarian  activity  and 
the  nutritive  processes  is  illustrated  by  the  fact  that,  on  reducing  their 
weight,  such  patients  may  again  menstruate  with  a  fair  degree  of 
regularity,  the  flow  again  disappearing  as  they  return  to  their  former 
state  of  obesity.  Premature  atrophy  has  resulted  from  alcoholism, 
syphilis,  the  acute  exanthemata,  rheumatism,  and  typhoid  fever, 
though  in  the  febrile  diseases  there  is  probably  a  previous  inflamma- 
tory process  in  the  ovary.  Prolonged  pressure  upon  an  ovary,  in  con- 
nection with  uterine  fibroids  and  broad  ligament  cysts  or  disturbance 
of  its  vascular  supply  by  dense  adhesions  and  exudates,  may  lead  to 
complete  glandular  atrophy  in  young  subjects.  So-called  cirrhosis  is 
often  erroneously  described  as  an  inflammatory  process.  Fibrous  de- 
generation would  be  a  more  accurate  term.  While  it  may  represent  the 
termination  of  a  previous  acute  inflammation,  it  is  usually  a  form  of 
chronic  hyperplasia  in  which  the  follicles  are  entirely  destroyed  and 
the  ovary  is  transformed  into  a  mass  of  firm  connective  tissue.  Such 
ovaries  are  often  associated  with  chronic  salpingitis  and  pelvic  exu- 
dates, leading  to  the  inference  that  obstruction  to  the  blood  supply 
is  mainly  responsible  for  this  form  of  atrophy.  Atrophic  changes  may 
follow  supravaginal  amputation  of  the  uterus  when  one  or  both  ova- 
ries have  been  left  in  situ. 

592 


TROPHIC   DISEASES   OF   THE   OVARIES  593 

Pathology. — An  atrophied  ovary  differs  in  its  microscopic  appear- 
ance from  the  organ  after  the  normal  climacteric,  not  so  much  in  size, 
as  in  its  irregular,  nodular  shape,  and  dense,  almost  cartilaginous, 
consistence.  The  cortex  is  much  thickened,  often  from  accompanying 
perioophoritis.  On  section,  the  surface  presents  a  uniformly  firm, 
fibrous  structure,  with  few  or  no  traces  of  follicles.  When  these  are 
present,  they  are  either  atrophied,  or,  rarely,  dropsical,  their  walls 
being  greatly  thickened.  The  arteries  are  few  and  their  lumina  con- 
tracted, and  there  are  no  evidences  of  leucocytic  foci. 

Symptoms. — There  are  no  symptoms  characteristic  of  atrophy,  if 
we  except  amenorrhoea  and  sterility  in  cases  in  which  both  ovaries 
are  affected  and  sexual  appetite  is  in  consequence  diminished  or 
absent.  Previously  to  complete  atrophy,  menstruation  is  irregular  and 
painful,  especially  when  the  glands  are  buried  in  adhesions.  In  fact, 
the  symptoms  are  due  rather  to  the  accompanying  condition. 

Prognosis. — Great  circumspection  is  necessary  in  giving  a  progno- 
sis in  these  eases,  or  in  promising  certain  definite  results  from  treat- 
ment. It  is  idle  to  expect  an  anatomical  cure  or  restoration  of  func- 
tion in  an  ovary  in  which  the  normal  stroma  and  follicles  have  com- 
pletely disappeared.  In  the  case  of  the  young  obese  subjects  before 
alluded  to,  in  whom  the  uterus  is  still  of  normal  size,  rigid  diet  and 
exercise,  baths,  electricity,  and  massage  (and  especially  a  course  at  a  for- 
eign spa,  such  as  Marienbad)  may  stimulate  the  ovaries  to  renewed 
functional  activity.  The  possibility  of  conception  is  doubtful,  so  that 
it  is  not  right  to  encourage  the  patient  with  false  hopes. 

Treatment. — When  the  atrophied  organs  are  adherent  and  give 
rise  to  constant  pain  and  dysmenorrhoea,  little  is  to  be  expected  except 
from  operative  intervention.  In  the  case  of  young  women  who  desire 
to  preserve  their  ovaries  it  may  be  sufficient  to  separate  adhesions,  in 
fact,  the  writer  once  saw  menstruation  return  and  persist  after  this 
simple  procedure;  but  when  the  flow  has  ceased  entirely  and  the  glands 
are  transformed  into  mere  fibrous  nodules,  there  is  no  object  in  retain- 
ing them. 

Cirrhosis  of  the  ovaries  requires  at  least  brief  consideration.  It 
has  been,  and  is  still,  the  custom  to  regard  the  condition  of  the  ovaries 
known  as  cirrhosis,  as  a  mere  sequence  of  an  acute  oophoritis.  But 
there  is  ample  evidence  that  this  condition  may  occur  independently 
of  inflammation.  It  is  found  fully  developed  without  antecedent  his- 
tory of  infection  in  women  under  thirty  years  of  age,  and  it  may 
involve  one  or  both  ovaries.  It  gives  rise  to  severe  pain  in  the  affected 
ovary,  especially  before  menstruation.  Its  persistence  may  lead  to 
neurasthenia  or  to  some  other  form  of  neurosis.  The  ovary  in  these 
cases  may  or  may  not  be  prolapsed,  is  firm,  unyielding,  globular  in 
form,  sensitive  to  the  touch,  but  usually  not  adherent.  In  the  earlier 
stages  of  the  disease,  the  ovary  presents  a  relatively  normal  appear- 
ance, but  as  the  morbid  process  progresses,  as  it  usually  does,  the 
organ  contracts  at  the  expense  of  the  vascular  stroma  or  medullary 
39 


594  '  A   TEXT-BOOK  OP   GYNECOLOGY 

substance  until  all  true  gland  tissue  has  been  destroyed.  As  a  result 
of  the  fibrous  contractions  the  surface  of  the  ovary  is  made  to  resem- 
ble, in  miniature,  the  convolutions  of  the  brain.  It  will  follow  as  a 
natural  conclusion  that  the  majority  of  women  suffering  from  cir- 
rhotic ovaries,  are  sterile. 

The  symptoms  are  not  always  constant.  So  true  is  this,  that  the 
patient  can  seldom  state  definitely  when  they  began.  The  pain  has 
been  described  as  of  a  sharp,  darting,  sickening  or  throbbing  char- 
acter, in  one  or  both  ovarian  regions,  but  more  frequent  and  severe 
in  character  in  the  left  ovary.  This  pain  has  its  greatest  intensity 
from  a  few  days  to  two  weeks  prior  to  the  menstrual  period,  and  is 
usually  accompanied  with  nervous  reflexes,  such  as  hysterical  mani- 
festations, backache,  etc.  In  many  of  the  cases,  owing  to  the  intimate 
nerve  connection  with  the  lumbar  ganglia  of  the  spinal  nerves,  pain 
will  be  referred  to  the  front  and  inner  side  of  the  thigh  and  to  the 
hip  joint.  Dyspareunia  is  absent  in  many  cases,  owing  to  the  fact  that 
the  ovaries  are  small  and  are  not  prolapsed  and  tender. 

In  the  early  stage  of  these  cases  they  may  be  treated,  with  some 
relief  of  the  pain,  by  electricity,  but  the  results  from  this  agent  have 
not  been  at  all  satisfactory.  All  cirrhotic  ovaries  do  not  require  re- 
moval. It  is  in  cases  where  other  means  have  failed,  and  where  the 
woman  has  been  rendered  an  invalid  or  her  suffering  has  become  almost 
intolerable,  that  the  removal  becomes  imperative. 

Hypertrophy  of  the  Ovaries. — This  may  be  defined  as  an  enlarge- 
ment of  the  ovary,  the  result  of  former  inflammation  or  chronic  con- 
gestion. It  is  cystic  or  fibrous,  according  as  the  change  affects  the 
follicles  or  stroma,  though  the  two  conditions  are  commonly  associ- 
ated. 

Causes. — So-called  chronic  oophoritis  leading  to  hypertrophy,  ac- 
cording to  Coe,  is  doubtless  the  termination  of  an  acute  inflammatory 
process,  which  does  not  terminate  in  abscess  formation,  hence  it  may 
be  due  to  puerperal  or  gonorrhoeal  infection  associated  with  similar 
disease  in  the  tube.  But  the  most  common  cause  is  long-standing 
pelvic  congestion,  such  as  accompanies  tubal  disease,  peritonitis,  and 
uterine  and  ovarian  tumours.  A  prolapsed  ovary,  especially  when 
surrounded  by  exudate,  is  liable  to  undergo  hypertrophy.  Chronic 
constipation  also  is  an  exciting  cause,  which  fact  may  account  for  the 
relatively  greater  frequency  of  hypertrophic  changes  in  the  left  ovary, 
which  is  not  only  in  close  proximity  to  the  sigmoid  flexure  but  has 
a  valveless  vein.  Primary  hypertrophy  is  sometimes  traceable  to  sex- 
ual excess,  traumatism,  or  frequent  pregnancy  and  abortion.  Cystic 
degeneration  may  result  from  disease  of  the  individual  follicles  which 
are  prevented  from  reaching  the  surface  of  the  ovary  or,  when  situ- 
ated in  the  peripheral  zone,  can  not  rupture  in  consequence  of  patho- 
logic thickening  of  their  walls  or  peri-oophoritic  adhesions  or  exudates. 

Pathology. — The  follicles  become  dropsical  and  few  or  many  cysts 
develop.     A  hypertrophied  ovary  may  be  enlarged  to  several  times 


TROPHIC  DISEASES  OP   THE  OVARIES  595 

its  normal  size,  and  presents  an  irregular  shape,  with  one  or  more 
cysts  of  variable  size,  sometimes  as  large  as  English  walnuts,  project- 
ing above  its  surface;  on  palpation,  there  is  a  more  or  less  distinct 
sense  of  fluctuation.  Or,  if  the  fibrous  element  predominates,  the 
ovary  may  be  globular  or  oval  in  shape,  with  a  smooth  whitish  appear- 
ance and  firm  consistence.  Fibroid  ovaries  are  usually  prolapsed, 
from  their  increased  weight,  and  are  often  freely  movable,  though  if 
there  is  accompanying  tubal  disease  they  are  apt  to  be  buried  in  exu- 
date. On  section,  such  an  ovary  shows  marked  thickening  of  the 
cortex,  with  general  induration  of  the  stroma  due  to  proliferation  of 
the  fibrous  tissue.  A  few  small  cysts  with  thickened  walls  are 
seen,  or  no  traces  of  the  follicles  remain.  The  walls  of  the  arteries 
are  usually  thickened,  the  lumina  are  dilated  and  hyaline  degenera- 
tion is  common.  In  cystic  hypertrophy  the  walls  of  the  dropsical  fol- 
licles are  thickened  and  they  contain  a  clear  fluid,  normal,  or,  not 
infrequently,  a  single  cyst  may  encroach  upon  the  stroma  to  such  an 
extent  that  only  a  narrow  zone  remains. 

Symptoms  and  Diagnosis. — The  symptoms  are  often  due  princi- 
pally to  coexisting  conditions — adhesions,  tubal  disease,  or  neoplasms. 
In  uncomplicated  cases,  the  patient  complains  of  severe  pain  in  one 
or  both  groins  or  in  the  sacrum,  which  is  increased  a  day  or  two 
before  the  menstrual  flow,  sometimes  recurring  in  a  paroxysmal  form 
during  the  intermenstrual  period.  The  pain  may  radiate  down  the 
thighs  and  is  often  accompanied  by  reflex  neuralgige  of  the  inter- 
costal nerves  and  pelvic  organs.  If  the  ovary  is  prolapsed  in  Doug- 
las's pouch,  a  peculiar  sickening  pain  is  felt  during  defecation  and 
coitus.  Locomotion  is  often  attended  with  severe  pain  in  the  groins 
and  sacrum,  extending  down  the  lower  limbs;  if  the  ovary  is  fixed  by 
adhesions  these  symptoms  are  aggravated.  Menstruation  is  apt  to  be 
irregular.  Menorrhagia  is  common  in  connection  with  cystic  hyper- 
trophy. Sterility  results  from  the  general  disappearance  of  the  nor- 
mal gland  tissue,  though  conception  is  always  possible  so  long  as 
healthy  follicles  persist.  The  effect  of  the  local  disturbances  upon 
the  general  health  may  be  such  that  the  patient  becomes  a  nervous 
invalid.  The  various  hystero-neuroses  are  frequently  referable  to  the 
ovarian  condition. 

Treatment. — The  treatment  is  palliative  or  surgical  according  to 
the  extent  of  the  disease  and  the  severity  of  the  symptoms.  Sexual 
intercourse  must  be  controlled,  and  rest  during  menstruation  insisted 
upon.  Hot  vaginal  douches  and  regulation  of  the  bowels  are  routine 
measures  in  every  case.  Ichthyol  tampons  often  accomplish  unex- 
pected results,  especially  in  the  case  of  tender  ovaries  which  are  adher- 
ent in  the  cul-de-sac.  Local  galvanism  and  the  fine  wire  secondary 
faradic  current  often  relieve  pain  to  a  marked  degree.  Pelvic  mas- 
sage is  useful  in  the  absence  of  subacute  inflammation,  or  accompany- 
ing pyosalpinx  or  hematosalpinx.  The  bromides  are  indicated  to 
allay  nervous  manifestations.     To  relieve  dysmenorrhoea,  the  coal-tar 


596        '    A  TEXT-BOOK  OF  GYNECOLOGY 

derivatives,  viburnum  compound,  and  apiol  are  useful.  Opium  should 
be  used  with  caution,  preferably  in  the  form  of  codeine.  Postural 
treatment  during  menstruation  (raising  the  hips,  or  even  the  Tren- 
delenburg position)  sensibly  diminishes  the  throbbing  pain  due  to 
excessive  pelvic  congestion.  Before  resorting  to  operative  procedures, 
nonsurgical  treatment  should  receive  a  fair  trial,  and  an  examination 
should  be  made  under  anesthesia  in  order  to  determine  the  extent 
of  the  disease. 

An  ovary  adherent  in  Douglas's  pouch  may  be  readily  reached  by 
vaginal  section  (preferably  through  the  posterior  fornix),  freed  from 
its  adhesions,  and  examined  with  a  view  to  the  necessity  of  removal. 
The  abdominal  route  doubtless  enables  the  operator  to  study  the  con- 
ditions more  intelligently  and  to  separate  thoroughly  all  adhesions. 
Conservative  surgery  should  be  practised  whenever  this  is  possible, 
especially  in  cases  of  cystic  hypertrophy.  An  ovary  which  is  merely 
prolapsed  and  is  not  generally  diseased  may  be  simply  sutured  in  its 
normal  position.  There  is  no  object  in  trying  to  save  one  which  is 
the  seat  of  general  fibroid  hypertrophy,  with  no  trace  of  normal 
follicles. 

When  both  ovaries  are  similarly  diseased  and  the  tubes  are  also 
generally  affected,  it  is  better  to  remove  the  adnexa  on  both  sides, 
especially  if  the  woman  has  long  been  sterile.  But  her  wishes  must, 
of  course,  have  considerable  weight.  No  fixed  rule  can  be  formulated 
to  fit  every  case,  as  the  surgeon  must  decide  for  himself  regarding  the 
extent  of  the  disease  and  whether  the  best  interests  of  the  patient 
will  be  served  by  a  conservative  or  a  radical  operation. 


CHAPTER    XL 

NEOPLASMS   OF   THE   OVARIES 

Benign  neoplasms:  Small  benign  cysts;  simple  or  follicular  cysts,  cysts  of  the 
corpus  luteum,  tubo-ovarian  cysts:  Neoplastic  cysts;  proliferating  cysts  and 
their  varieties;  dermoid  cysts  and  their  varieties:  Solid  tumours;  fibroma, 
calcified  tumours — Hematoma  —  Malignant  neoplasms:  Primary  carcinoma; 
medullary  carcinoma;  adenocarcinoma;  secondary  carcinoma:  Sarcoma:  En- 
dothelioma. 

Neoplasms  of  the  ovaries  are  of  frequent  occurrence,  and  of  several 
varieties.  There  is  probably  no  organ  in  the  body  that  is  so  suscep- 
tible to  neoplastic  changes.  These  will  be  considered  in  the  following 
order : 

Benign"  jSTeoplasms: 

1.  Small   benign  cysts:    (a)   follicular   cysts,   (&)   cysts   of  the 

corpus  luteum,  (c)  tubo-ovarian  cysts. 

2.  Neoplastic   cysts:     (a)   proliferating   cysts   (pseudomucinous 

and  serous),  (&)   dermoid  cysts. 

3.  Solid  Tumours:    (a)  fibroid  tumours,  (b)  calcified  tumours. 

4.  Hematoma. 

Malignant  jSTeoplasms  : 

1.  Carcinoma:    (a)  primary,  (&)  secondary. 

2.  Sarcoma. 

3.  Endothelioma. 

Benign  JSTeoplasms 

Small  Benign  Cysts  of  the  Ovary. — The  ovary  by  reason  of  its 
peculiar  anatomic  structure  is  greatly  predisposed  to  cyst  formation, 
and  perhaps  this  tendency  is  shared  by  no  other  organ  of  the  body  to 
the  same  extent. 

The  smaller  cyst  formations  have  been  variously  named,  as 
hydrops  folliculi,  hypertrophy  of  the  follicle  (Ziegler),  small  cystic 
degeneration  (Hegar),  and  follicular  cysts. 

Slightly  dilated  follicles  and  small  follicular  cysts  are  distin- 
guished by  no  essential  difference  in  appearance;  so  that  the  clinician 
is  often  perplexed  to  determine  what  constitutes  the  degree  of  cyst 
formation  to  be  designated  pniliologic. 

597 


598  A   TEXT-BOOK   OF   GYNECOLOGY 

Between  the  somewhat  dilated  follicles  so  frequently  met  with 
as  an  accompaniment  of  chronic  oophoritis,  and  true  cysts,  no  sharp 
dividing  line  can  be  drawn,  so  that  frequently  a  careful  histological 
study  is  necessary  before  each  can  be  placed  in  its  proper  class.  Mar- 
tin {KranMeiten  der  Eierstocke,  S.  324)  has  proposed  to  regard  as 
hydrops  folliculi  those  dilated  follicles  which  reach  a  size  whose  diam- 
eter is  not  greater  than  the  thickness  of  the  normal  ovar}^,  and  to  desig- 
nate as  true  cysts  only  those  reaching  a  greater  size.  Winter  {Gynakolo- 
gische  DiagnosWk,  page  174),  on  the  other  hand,  reserves  the  term 
cystic,  to  be  applied  to  those  ovaries  which  reach  the  size  of  a 
hen's  egg. 

Pathologic  cyst  formation  of  the  ovary  is  primarily  divided  into 
two  groups : 

1.  Simple  or  follicular  cysts. 

2.  Neoplastic  cysts. 

To  the  first  group  belong  (a)  follicular  cysts;  (b)  cysts  of  the 
corpus  luteum;  (c)  tubo-ovarian  cysts;  while  under  the  second  group 
are  usually  classed   {a)   proliferating  cysts;   (b)   dermoid  cysts. 

Simple  or  FoMcular  Cysts. — Various  theories  have  been  advanced 
in  explanation  of  the  development  of  follicular  cysts,  but  in  the  ma- 
jority of  instances  they  are  probably  due  to  previous  inflammatory 
changes  in  the  ovary,  the  fibrous  tunic  of  which  has  become  thickened, 
thus  preventing  the  rupture  of  the  follicle,  and  are  therefore  reten- 
tion cysts.  According  to  Olshausen,  they  frequently  develop  in  the 
following  manner:    In  the  beginning,  the  ovary  will  contain  several 

dilated  follicles  (Fig.  249),  which  mate- 
rially increase  its  size;  sooner  or  later, 
one  of  the  follicles  takes  on  abnormal 
growth  and  expands  on  the  surface  of  the 
ovary  in  the  direction  of  least  resistance. 
Pressure  from  the  increasing  contents 
produces  atrophy  of  its  wall  which  be- 
comes thin.  When  the  cyst  reaches  some 
Fig  249  (Whitacbe).-"!!!  the      ^-^^    ^j.-       ^50),    it    replaces    the    ovary, 

beginnmg,  the  ovary  will  con-  i  •   i      i  ^  n    j,  n     i? 

tain  several  dilated  follicles."-      which   has   now   become    flattened    trom 
EoTHRocK.  pressure,  and  appears  as  a  mere  thicken- 

ing of  the  basal  wall  of  the  cyst,  while  the 
peripheral  wall  of  the  cyst  is  thin.  As  a  rule,  they  develop  on  the  sur- 
face of  the  ovary,  the  walls  of  which  are  thick  and  consist  largely  of 
ovarian  tissue.  Follicular  cysts  may  be  freely  movable  and  even  pedun- 
culated or  they  may  develop  within  the  ligament. 

They  vary  in  size  from  that  of  a  pigeon's  egg  to  that  of  an  orange, 
though,  exceptionally,  much  larger  cysts  have  been  met  with,  reaching 
the  size  of  an  adult's  head. 

The  wall  of  the  cyst  varies  in  thickness,  and  the  external  surface 
may  be  smooth  and  shining,  or  rough  from  adhesions.  The  inner  sur- 
face of  the  cyst  wall  is  as  a  rule  smooth,   shining,   and  fascialike. 


NEOPLASMS  OF   THE   OVARIES 


599 


though  occasionally  a  few  small  wartlike,  papillary  growths,  are  ob- 
served springing  from  the  surface. 

Follicular  cysts  are  usually  unilocular,  though  sometimes  two  or 
more   cysts  may   fuse,   in  which   case  the   remains   of   partitions   or 
trabeculalike    forma- 
tions may  be  seen. 

In  the  early  stages 
of  development  so 
soon  as  the  follicle 
begins  to  dilate,  the 
ovum  dies  and  the 
membrana  granulosa 
undergoes  fatty  de- 
generation and  dis- 
appears. 

The  cyst  con- 
tents, which  repre- 
sent the  epithelial 
secretion  with  per- 
haps some  transuda- 
tion from  the  blood 
vessels,  consist  of  a 
thin  clear  straw-col- 
oured fluid  with  a 
specific  gravity  of 
from  1.005  to  1.026, 
and  may  at  times  be 

blood-tinged  or  turbid.  As  a  rule,  the  sediment  is  small,  and  contains  a 
few  formed  elements  consisting  chiefly  of  degenerated  epithelial  cells, 
fat  drops,  and  at  times  a  few  blood  corpuscles  and  cholesterin  crystals. 

Histologically,  the  wall  of  the  cyst  is  composed  of  connective  tis- 
sue with  occasionally  some  ovarian  stroma.  The  internal  surface  is 
lined  with  low  cylindrical  or  cuboidal  cells,  or  it  may  be  without  epi- 
thelial lining. 

Cysts  of  the  Corpus  Luieum,. — The  observations  of  IsTagel,  Bulius 
and  Frankel,  prove  beyond  doubt  that  cysts  may  develop  in  the  rup- 
tured as  well  as  in  the  unruptured  follicle.  To  liokitansky,  however, 
belongs  the  credit  of  being  the  first  to  describe  cysts  of  the  corpus 
luteum.  Like  follicular  cysts,  they  are  of  slow  growth  and  rarely  reach 
large  size,  usually  not  larger  than  a  walnut,  though  in  a  few  instances 
they  have  been  observed  as  large  as  a  foetal  head,  and,  rarely,  as  large  as 
a  man's  head.  They  are  usually  solitary,  but  two  have  been  observed  in 
the  same  ovary. 

In  the  beginning,  they  are  usually  situated  in  one  or  the  other  pole 
of  the  ovary  (Fig.  351),  but  as  they  increase  in  size  they  gradually 
replace  the  ovary,  which  appears  as  a  flattened  mass  on  the  cyst  wall. 
Like  follicular  cysts,  they  are  unilocular,  but  differ  very  materially  in 


Fig.  250  (Pfannen>tii:i.  i.      ■  W  li. n  ihc  cyst  reaches  some 
size  it  replaces  the  ovary." — Kotiieock  (page  598}. 


600 


A   TEXT-BOOK  OF   GYNECOLOGY 


Fig.  251  (Whitacre).—"  Cysts  of 
the  corpus  luteum  .  .  .  are  usu- 
ally situated  in  one  or  the  other 
pole  of  the  ovary." — Kothrock 
(page  599). 

laries.    In  a  few  instances 


having  thick  walls  made  up  of  two  layers,  which  may  be  easily  sepa- 
rated from  each  other.  The  inner  stratum,  which  is  called  the  lutein 
layer,  is  arranged  in  folds,  and  is  further  characterized  by  being  of  a 

yellow  orange  or  brown  colour.  The  outer 
layer  represents  the  tunica  fibrosa  of  the 
normal  corpus  luteum. 

The  cyst  contents  consist,  in  most 
instances,  of  a  clear  serous  fluid,  which 
is  probably  the  product  of  transudation 
from  the  very  vascular  lutein  layer  of  the 
cyst.  Microscopically,  they  differ  widely 
in  appearance.  In  some  cysts,  the  inner 
stratum  is  of  typical  corpus-luteum  struc- 
ture, consisting  of  large  epithelioid  cells 
lying  thickly  in  a  scant  network  of  fibril- 
lary connective  tissue  very  rich  in  capil- 
the  innermost  layer  has  been  found  to  con- 
sist wholly  of  connective  tissue  (L.  Frankel,  Archiv  filr  Gynakologie, 
Bd.  Ivi,  H.  2). 

The  recent  observations  of  Orthmann  and  L.  Frankel  leave  no 
doubt  that  occasionally  cysts  of  the  corpus  luteum  may  be  lined  by 
epithelium.  The  character  of  the  epithelium  is  usually  cylindrical,  but 
may  be  cuboidal  or  approach  the  squamous  type.  The  cells  are  not 
always  regularly  arranged,  but  may  be  here  and  there  set  diagonally 
to  the  surface. 

The  etiology  of  these  cysts  is  not  known.  The  frequent  coexistence, 
however,  of  chronic  oophoritis  suggests  that  the  chronic  hypergemia 
incident  thereto,  may  have  been  the  determining  cause  of  the  increased 
transudation  which  gave  rise  to  cyst  formation. 

Blood  cysts  constitute  another  variety  of  cysts  of  the  corpus  luteum, 
which  are  not  so  uncommonly  met  with,  and  are  of  much  pathological 
interest  and  clinical  significance. 

Attention  has  been  called  to  these  cysts  by  certain  French  writers, 
as  Robin,  Rollin,  Doleris,  Petit,  and  especially  Pilliet. 

More  recently,  Orthmann  {Verhandlwigen  der  deutschen  Gesellschaft 
filr  Gynakologie,  1897)  has  made  a  careful  and  exhaustive  study'  of 
these  cysts,  and  concludes  that  they  originate  from  hemorrhage  into 
the  corpus  luteum. 

According  to  Orthmann,  these  cysts  are  usually  superficial,  and 
are  most  frequently  found  at  one  or  other  pole  of  the  ovary.  They 
are  round  or  oval  in  shape,  and  vary  in  size  from  that  of  a  walnut  to 
that  of  the  head  of  a  newborn  child.  They  are  frequently  firmly  ad- 
herent to  the  surrounding  structures  and  may  be  bilateral. 

According  to  Orthmann,  it  is  not  always  possible  to  distinguish 
between  these  blood  cysts  and  primary  cysts  of  the  broad  ligament 
into  which  hemorrhage  has  taken  place,  and  they  may  be  confused 
with  ovarian  pregnancy. 


NEOPLASMS  OF  THE   OVARIES 


601 


The  cyst  contents  vary.  In  small  cysts,  the  blood  may  be  coagulated, 
while,  in  the  larger  ones,  it  is  usually  liquid  and  of  a  reddish,  dark 
brown,  or  chocolate  colour.  On  section,  one  finds  the  cyst  wall  composed 
of  the  characteristic  structure  of  corpus-luteum  cysts  (Fig.  252). 

In  small  as  well  as  in  large  cysts,  the  inner  wall  is  uneven  and 
more  or  less  strongly  folded,  and  is  of  a  yellow  or  brown  colour. 

The  microscopic  appearance  of  the  wall  of  the  cyst  is,  in  many 
cases,  similar  to  that  of  corpus-luteum  cysts  already  described;   while, 
in  others,  there  are  present  many  of  the  histological  changes  occurring 
in  the  various  stages  in  the  pro- 
cess of  regeneration  of  the  normal 
corpus  luteum.     Like  corpus-lu- 
teum cysts,  they  may  sometimes 
be  lined  with  epithelium. 

Tubo-ovarian  Cysts.  —  Cysts 
are  occasionally  encountered 
which  involve  both  the  ovary  and 
the  Fallopian  tube.  Various  the- 
ories have  been  advanced  in  ex- 
planation of  such  cyst  formation, 
but  from  the  great  variety  which 
have  been  described,  it  is  evident 
that  no  one  theory  will  explain 
all  cases.  It  is  probable,  however, 
that  pelviperitonitis  with  result- 
ing adhesion  of  the  pavilion  of 
the  tube  to  the  ovary,  is  primarily 
an  important  factor  in  their  for- 
mation. The  exhaustive  studies  of  Eosthorn  have  done  much  to  eluci- 
date this  subject.  He  concludes  that  tubo-ovarian  cysts  may  develop 
from  any  one  of  the  following  conditions,  which  he  divides  into  two 
groups:   The  first  group  includes: 

(a)  Cases  in  which  a  pyosalpinx  becomes  adherent  to  the  wall  of  a 
coexistent  abscess  of  the  ovary,  with  subsequent  perforation  of  the 
wall  separating  them. 

(h)  Adhesion  of  the  pavilion  of  the  tube  to  the  wall  of  a  suppu- 
rating ovarian  cyst,  with  subsequent  development  of  a  hydrosalpinx 
and  perforation  of  the  cyst  into  the  tube. 

(c)  Adhesions  of  a  hydrosalpinx  to  a  papillomatous  cyst,  with  sub- 
sequent perforation  of  the  intervening  wall  by  papillary  growths. 

To  the  second  group  belong : 

(a)  Cases  in  which  a  hydrosalpinx  becomes  adherent  to  the  wall 
of  a  follicular  cyst,  with  subsequent  perforation  of  the  septum. 

(h)  Cases  in  which  the  fimbriae  of  a  previously  diseased  tube  be- 
come caught  in  the  opening  of  a  ruptured  follicle  at  the  moment  of 
rupture,  and  become  adherent  to  the  wall  of  the  follicle  with  the 
devolopmont  of  a  tubo-corpus-liiteinn  cyst. 


Fig.  252  (Whitacee). — "  On  section,  one  finds 
the  cyst  wall  composed  of  the  character- 
istic structure  of  corjDus-luteum  cysts." — 

EOTHBOCK. 


602 


A  TEXT-BOOK  OF   GYNECOLOGY 


While  undoubted  instances  of  each  of  these  modes  of  origin  have 
been  observed,  the  classical  tubo-ovarian  cyst  is  of  follicular  origin, 
and  only  rarely  are  proliferating  cysts  communicating  with  a  dilated 
Fallopian  tube  encountered. 

These  cysts  are  usually  unilateral,  though  they  may  be  bilateral, 
and  they  vary  in  size  from  that  of  a  pigeon's  egg  to  that  of  a  closed 
fist,  and,  exceptionally,  larger  ones  have  been  observed.  The  junction 
of  the  tubal  portion  of  the  cyst  with  the  cyst  proper,  is  marked  by  a 
sharp  flexion,  giving  it  the  peculiar  and  characteristic  appearance  of 
a  retort  (Fig.  213,  p.  498). 

As  a  rule,  the  larger  portion  of  the  cyst  is  developed  from  the 
ovary,  and  is  round  or  oval.  The  cyst  wall  is  usually  smooth,  if  not 
adherent,  and  in  large  cysts  may  be  quite  thin.  In  most  instances, 
it  is  more  or  less  adherent  to  the  surrounding  structures. 

Tubo-ovarian  cysts  are  unilocular,  and  not  infrequently  they  com- 
municate with  the  uterine  cavity,  through  which  the  contents  are 
periodically  emptied.  The  opening  between  the  ovarian  and  tubal 
portions  of  the  cyst  varies  in  size,  and  is  frequently  guarded  by  a 
valvelike  formation,  the  remains  of  the  septum  (Fig.  253). 

The  cyst  contents 
consist  usually  of  a  clear 
serous  fluid  similar  to 
that  of  follicular  cysts. 
They  may,  however,  be 
turbid,  blood-tinged,  or 
chocolate  -  colour  from 
disorganized  blood. 

Histologically,        the 
wall  of  the  cyst  is  com- 
posed of   connective  tis- 
sue, while,  in  the  tubal 
portion,    atrophied    mus- 
cle   fibres    may    be    ob- 
served.      The    epithelial 
lining  of  the  ovarian  por- 
tion   of    the    cyst    con- 
sists of  low  cylindrical,  cuboidal,  or  spindle-shaped  cells,  or  may  be 
without  epithelial  lining,  while  the  tubal  portion  of  the  cyst  is  lined 
with  cylindrical  epithelium  which  is  frequently  ciliated. 

Neoplastic  Cysts. — Proliferating  cysts  constitute  by  far  the  greater 
proportion  of  tumours  of  the  ovary.  They  have  been  variously  desig- 
nated as  simple,  compound,  areolar,  unilocular  and  multiloeular, 
colloid  and  myxomatous  cysts,  all  of  which  are  clinical  distinctions 
depending  upon  their  most  striking  features.  Waldeyer  divided  pro- 
liferating cysts  into  two  groups :  Proliferating  glandular,  and  prolif- 
erating papillary  cysts,  according  as  they  contained  papillary  growths, 
or  not;  and  this  division  has  been  generally  followed  by  most  writers 


Fig.  253  (Martin). — "  The  opening  between  the  ova- 
rian and  tubal  portions  of  the  cyst ...  is  frequently 
guarded  by  a  valvelike  formation." — Rotiirock. 


NEOPLASMS  OP   THE  OVARIES  603 

to  the  present  time.  It  will  be  observed  that  this  is  a  purely  clinical, 
and  rather  vague  and  indefinite,  ground  for  division,  based  entirely 
upon  macroscopic  appearance  and  admitting  of  no  very  sharp  dis- 
tinction, since  many  cysts  come  under  observation  in  which  the  char- 
acteristic features  of  both  are  present  to  an  almost  equal  degree. 
The  most  satisfactory  division  yet  made,  and  one  founded  on  a  chem- 
ical and  anatomical  basis,  and  at  the  same  time  admitting  of  marked 
clinical  distinctions,  is  that  recently  proposed  by  Pfannenstiel.  Leav- 
ing out  of  consideration  mere  clinical  appearance,  Pfannenstiel  sought 
to  distinguish  ovarian  cysts  by  the  chemical  constituents  of  their  con- 
tents, and  found  that  a  large  proportion  of  cysts  contained  a  chemical 
substance  long  known  and  formerly  called  paralbumin  and  metalbu- 
min.  Hammarsten,  however,  found  that  it  was  not  an  albumin,  but  a 
substance  resembling  mucin,  which  he  termed  pseudomucin.  In  a 
smaller,  and  at  the  same  time  clinically  sharply  differentiated  class 
of  cysts,  Pfannenstiel  found  that  this  substance  was  not  present  in 
the  contents.  Carrying  his  investigation  further,  he  discovered  that 
they  differed  histologically  in  the  character  of  their  epithelial  lining. 
In  the  first  group,  the  cells  were  cylindrical  and  resembled  mucous 
cells,  while  in  the  second  group,  the  cysts  were  lined  by  ciliated  co- 
lumnar epithelium.  He  further  observed  that  the  two  groups  differed 
greatly  in  the  gross  appearance  of  their  contents.  Those  of  the  first 
group  were  more  or  less  thick,  turbid,  and  often  colloid,  in  appearance, 
while  in  the  other,  they  were  thin,  clear,  and  serous.  He  therefore 
divided  all  proliferating  cysts  into — 

(1)  Pseudomucinous  cysts. 

(2)  Serous  cysts. 

Pseudomucinous  (Proliferating)  Cysts. — To  this  group  belong  the 
greater  proportion  of  ovarian  cysts.  They  are  usually  unilateral,  and 
they  vary  in  size  from  a  mere  beginning  cyst  only  sufficiently  large  to 
be  recognised,  to  tumours  of  enormous  dimensions,  often  filling  the 
abdominal  cavity,  displacing  other  viscera,  and  encroaching  seriously 
on  the  thoracic  cavity. 

Cartledge  has  reported  (Journal  of  the  American  Medical  Associa- 
tion, 1897)  the  largest  cyst  of  the  ovary  on  record.  The  tumour  had 
been  growing  for  thirteen  years,  and  for  the  last  four  years  very  rapidly, 
so  that  the  patient  had  been  unable  to  assume  a  reclining  posture  for 
more  than  a  year  and  a  half.  The  circumference  at  the  umbilicus  was 
79  inches.  The  woman  was  5  feet  4  inches  in  height  and  well  formed, 
except  that  she  was  very  much  emaciated  from  carrying  this  enor- 
mous cyst.  Twenty-four  gallons  of  ovarian  fluid  were  removed  before 
she  was  placed  in  position  to  be  anaesthetized.  After  that,  she  was 
placed  on  her  back  and  10  additional  gallons  of  fluid  withdrawn.  The 
adhesions  to  the  anterior  parietal  wall  were  terrific.  Many  ligatures 
were  used,  and  the  operation  consumed  about  two  hours  under  unfa- 
vourable circumstances.  The  woman  survived  the  operation  fairly 
well,  leaving  the  table  with  a  pulse  of  114.    On  the  fifth  day  she  had  a 


604 


A  TEXT-BOOK  OF   GYNECOLOGY 


normal  temperature  and  a  pulse  of  108.  Beginning  with  the  sixth  day, 
symptoms  of  intestinal  obstruction  developed  and  she  finally  died. 
The  fluid  withdrawn  weighed  240  pounds  and  the  sac  5  pounds. 

Other  very  large  tumours  have  been  reported,  one  successfully  re- 
moved by  Gilliam,  of  Columbus,  weighing  176  pounds.    A.  H.  Cordier 

has  reported  a  cyst  which 
weighed  160  pounds  (Fig. 
254).  Tumours  of  100 
pounds  are  occasionally 
encountered. 

It  is  no  longer  com- 
mon,   however,    to    meet 
with    such    large    cysts, 
inasmuch  as  surgical  aid 
is  usually  sought  before 
the     tumour    reaches     a 
great    size.      They    may 
occur   at   any   period    of 
life,  from  puberty  to  ad- 
vanced     age,      although 
they  are  most  frequent- 
ly    encountered     during 
the   childbearing   period, 
especially     from     thirty 
to  forty-five.    Unmarried 
and  sterile  women  seem 
to    be    especially    predis- 
posed.    Whether,  as  has 
been      suggested,      preg- 
nancy   and    lactation    by 
temporarily   interrupting 
the    menstrual    function 
afl^ord  a  protection  against 
tumour  formation  we  do 
not  know.     It  is  conceiv- 
able,   however,    that    the 
periodical  congestion  in- 
cident   to    menstruation, 
may  have  a  determining 
influence. 

The  shape  of  the  tu- 
mour is  usually  spherical, 
ovoid,  or  irregular  in  out- 
line.    If  small,  it  is  usu- 
ally irregular  in  shape  from  partial  fusion  of  two  or  more  cysts  pre- 
senting no  uniformity  of  structure.     Larger  tumours,  while  generally 
assuming  a  spherical  shape,  are  often  uneven  in  outline,  with  here  and 


Fig.  254.—"  A.  II.  Cordier  has  reported  a  cyst  which 
weighed  160  pounds." — Kothrock. 


NEOPLASMS   OP   THE   OVARIES 


605 


there  nodular  prominences  due  to  bulging  caused  by  smaller  cysts  de- 
veloping in  the  cyst  wall. 

Thp  external  appearance  of  the  tumour  is  pearly  white  or  bluish, 
often  smooth  and  glistening,  and  at  times  it  has  a  cartilaginous  ap- 
pearance. Over  the  surface,  blood  vessels  of  varying  size  are  fre- 
quently seen  ramifying.  Occasionally,  bands  of  unstriped  muscle 
fibre  and  the  remains  of  ovarian  stroma  are  to  be  seen  spread  out  over 
the  tumour,  especially  near  the  pedicle. 

On  section,  the  tumour  will  be  found  to  consist  of  a  conglomera- 
tion of  a  greater  or  less  number  of  cysts  (Fig.  255).  Usually,  one  cyst 
attains  a  considerable  size  and  constitutes  the  main  portion  of  the 
tumour,  while,  in  its  wall,  are  developed  numerous  smaller  cysts  which 
encroach  on  the  lumen  of  the  main  cyst.  Sometimes,  the  entire  number 
may^  be  composed  of 
a   conglomeration   of 


innumerable  small 
cysts,  separated  from 
each  other  by  a  more 
or  less  dense  struc- 
ture giving  it  on  sec- 
tion a  honeycombed 
appearance.  Usually, 
the  individual  cysts 
are  separated  from 
each  other  by  walls 
of  varying  thickness 
composed  of  highly 
vascularized  connec- 
tive tissue.  These 
septa  frequently  be- 
come very  thin  from 
pressure  atrophy,  and 
may  rupture,  result- 
ing in  fusion  of  several  cysts  with  intermingling  of  their  contents.  Fre- 
quently, the  remains  of  such  septa  may  be  seen  in  the  main  cyst  forming 
trabeculalike  processes  on  its  internal  surface.  Gradually,  these  septa 
disappear  from  pressure,  and  in  old  or  very  large  cysts,  the  entire  tumour 
may  consist  of  one  large  space,  though  usually  smaller  flattened  cystic 
spaces  will  be  found  in  its  walls.  The  internal  surface  of  the  cyst  is 
usually  smooth,  though  it  may  be  covered  here  and  there  with  wart- 
like excrescences,  dendritic,  or  caiiliflower  growths.  These  may  be  few 
or  quite  abundant.  As  a  rule,  the  larger  the  cyst,  the  smoother  will 
be  its  wall,  and  the  fewer  papillary  growths  it  will  contain.  These 
papillary  growths  differ  much  in  appearance.  They  are  usually  of  a 
gray  colour,  but  may  be  pink  or  dark  red  if  rich  in  blood  vessels. 

Tbe  cyst  contents  arc  the  product  of  cell  secretion  from  the  lining 
membrane.      The    contents    of    the    individual    cysts    composing    the 


Fig.  255  (Martin's  Handbook).— "  On  section,  the  tumour 
will  be  found  to  consist  of  a  conglomeration  of  a  greater 
or  less  number  of  cysts." — Kothkock. 


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A  TEXT-BOOK  OF  GYNECOLOGY 


tumour  may  present  the  greatest  diversity  of  appearance  and  consist- 
ence; one  obtained  by  Pfannenstiel  contained  a  bright  transparent 
body,  probably  a  degenerated  ovum  (Fig.  356).  In  general,  they  consist 
of  a  fluid  with  a  specific  gravity  of  from  1.010  to  1.030,  of  the  consist- 
ence of  honey,  though  at  times  it 


^SS3ftgg 


Fig.  25(3  (  X'eit's  llaudbook  ). — "  One  obtaiued 
by  Pfannenstiel  contained  a  bright  trans- 
parent   body,    probably    a    degenerated 

ovum." — KOTHROCK. 


W^S^^'^^*:^S:Sii^^^  ■  .-'-^-r^If^--^  niay  be  thick,  ropy,  and  gelatin- 
ous, especially  in  the  smaller 
cysts. 

In  colour  it  varies  quite  as 
much  as  in  consistence.  It  is 
usually  turbid,  and  often  has  the 
appearance  of  oily  water;  it  may 
be  gray,  yellowish,  greenish,  or 
wine-colour,  and  sometimes  it  is 
dark  brown  from  admixture  of 
blood. 

Microscopically,  it  is  usually 
poor  in  organized  elements,  being 
composed  chiefly  of  a  homogene- 
ous mass  which  may  contain  a  few  fat  globules,  degenerated  epithelial 
cells,  and,  at  times,  a  few  red  blood  corpuscles,  hematin  and  cholesterin 
crystals. 

The  cell  described  by  Drysdale  and  considered  by  him  a  pathog- 
nomonic diagnostic  sign  of  ovarian  cysts  is  no  longer  so  regarded. 

The  greatest  interest  attaches  to  the  chemical  constituents  of  the 
cyst  contents.  They  usually  consist  of  a  highly  albuminous  fluid 
which  contains  in  addition  a  peculiar  substance  named  pseudomucin. 
This  substance  varies  in  amount  in  different  cysts,  sometimes  consti- 
tuting almost  the  entire  cyst  contents,  and  again  it  is  present  only  in 
small  quantities.  Small  cysts  with  colloidlike  contents  are  the  richest 
in  this  susbstance.  Pseudomucin  is  a  glyeoproteid,  and  differs  from 
mucin  in  not  being  precipitated  by  acetic  acid.  It  is  further  character- 
ized by  setting  free  a  copper  reducing  substance  when  boiled  in  the 
presence  of  dilute  mineral  acid. 

Test  for  Pseudomucin. — The  following  is  the  test  proposed  by 
Pfannenstiel  and  is  a  modification  of  Hammarsten's  test.  To  the 
cyst  contents  is  added  twice  their  volume  of  alcohol  after  which  the  mix- 
ture is  well  shaken.  The  precipitate  is  then  filtered  and  well  washed 
with  alcohol,  after  which  it  is  gently  pressed  between  filter  papers  to 
remove  the  excess  of  alcohol.  A  portion  of  the  precipitate  is  now 
boiled  for  half  an  hour  in  a  lO-per-cent  solution  of  hydrochloric  acid. 
After  cooling,  it  is  treated  with  phosphorwolfram  acid  until  the  albu- 
min is  entirely  precipitated.  The  filtrate  is  filtered  and  tested  with 
Trommer's  or  Fehling's  test  for  sugar,  and  if  reduction  takes  place,  it 
may  be  concluded  that  pseudomucin  is  present. 

Histologically,  the  wall  of  the  cyst  is  made  up  of  three  layers.  The 
outer  represents  the  tunica  albuginea  of  the  ovary,  and  is  covered  with 


NEOPLASMS  OF  THE   OVARIES 


607 


germinal  epithelium  consisting  of  a  single  layer  of  low  cylindrical 
cells.  The  middle  layer  consists  of  connective  tissue  and  may  contain 
ovarian  stroma  or  smooth  muscle  fibres.  This  layer  also  contains  the 
larger  blood  vessels.  The  inner  layer  consists  of  cyst  epithelium  and 
is  covered  by  a  single  layer  of  peculiar  mucuslike  cells,  cylindrical  in 
type.  According  to  Pfannenstiel,  these  cells  show  a  special  affinity  for 
hematoxylon  and  eosin,  and  by  this  double  stain,  the  nuclei,  cell  con- 
tents, and  periphery,  are  clearly  differentiated. 

When  stained,  they  appear  as  high  cylindrical  cells  with  small  basal 
nuclei,  while  the  cell  body  consists  of  a  clear  transparent  mass  inclosed 
within  the  cell  wall,  which  appears  as  a  faint  outline.  Occasionally, 
the  cyst  wall  contains  small  ductlike  tubes  or  glands,  which  originate 
in  a  proliferation  and  invagination  of  the  cyst  epithelium  into  the 
wall  of  the  cyst.  Frequently,  instead  of  ductlike  invaginations,  their 
mouths  will  have  become  occluded  from  constriction  of  the  connective 
tissue  of  the  cyst  wall,  which  is  also  in  a  state  of  proliferation,  when 
they  will  appear  as  small  cysts. 
The  constant  repetition  of  this 
process  of  epithelial  proliferation 
throughout  the  tumour,  together 
with  the  increasing  contents  from 
increased  area  of  epithelial  secret- 
ing surface,  is  responsible  for  its 
growth  (Fig.  257). 

Papillary  cysts,  according  to 
Pfannenstiel,  develop  in  the  fol- 
lowing manner:  First,  a  prolifera- 
tion of  epithelium  takes  place 
which  causes  tilting  and  displace- 
ment from  crowding  of  the  cells, 
carrying  with  them  a  thin  vinder- 
lying  stratum  of  connective  tis- 
sue; this,  being  rich  in  blood  ves- 
sels, also  takes  on  proliferation.  In  many  instances,  the  connective- 
tissue  proliferation  appears  to  surpass  the  proliferation  of  the  epithe- 
lium, which  must,  however,  always  be  considered  primary. 

Serous  {Proliferating)  Cysts. — Serous  cysts  are  much  less  common 
than  the  pseudomucinous  variety,  occurring  in  the  proportion  of  about 
1  to  8  of  the  latter.  As  a  rule,  they  are  small,  and  never  reach  the 
enormous  dimensions  of  pseudomucinous  cysts,  although  cysts  the  size 
of  a  pregnant  uterus  at  term  have  been  observed. 

In  external  appearance,  they  resemble  somewhat  pseudomucinous 
cysts.  In  contrast  with  pseudomucinous  cysts  they  frequently  develop 
bilaterally.  While  they  may  lie  free  in  the  peritoneal  cavity,  attached 
by  a  well-formed  pedicle,  they  frequently  develop  within  the  folds  of 
the  broad  ligament,  and  show  a  special  tendency  to  become  attached 
to  the  neighbouring  viscera  by  adhesive  bands. 


Fig.  257  (Wiiitacee). — Epithelium  of  a 
pseudomucinous  cyst. — Kothrock. 


608 


A  TEXT-BOOK   OF   GYNECOLOGY 


On  section,  these  cysts  are  also  multilociilar,  though,  as  a  rule,  they 
seldom  contain  so  many  cysts  as  the  pseudomucinous  variety.  A  cer- 
tain proportion  of  serous  cysts,  especially  the  larger  ones,  may  appear 
macroscopically  as  unilocular  cysts,  but  microscopic  examination  will 
invariably  reveal  the  presence  of  small  cysts  within  the  walls  of  the 
tumour.  As  a  rule,  these  cysts  contain  papillary  growths,  and  they 
represent  the  type  of  proliferating  papillary  cysts  of  the  old  classifica- 
tion, just  as  the  glandular  type  is  represented  by  the  pseudomucinous 
variety.  Occasionally,  however,  serous  cysts  may  be  of  the  glandular 
type  and  contain  no  papillary  growths. 

Papillary  growths  may  be  very  abundant,  and  may  completely  fill 
smaller  cyst  cavities,  and  even  cause  rupture  by  pressure  from  in- 
creased contents,  or  they  may  grow  through  the  wall  of  the  cyst  caus- 
ing perforation.  Not  in- 
frequently, serous  cysts 
are  encountered  with 
papillary  growths  on 
their  surface  as  well  as  in 
their  interior  (Fig.  258). 
These  may  grow  direct 
from  the  germinal  epi- 
thelium, or  may  repre- 
sent a  continuation  of 
intracystic  papillary 
growths  which  have 
penetrated  the  wall  of  the 
cyst.  Such  cysts  are  al- 
most invariably  accom- 
panied by  ascites. 

The  contents  of  se- 
rous cysts  consist  of  a 
thin,  clear,  straw  -  col- 
oured or  greenish  fluid, 
rich  in  albumin  but  con- 
taining no  pseudomucin.  It  is  partly  derived  from  cell  secretion  and 
partly  from  transudation  from  the  blood  vessels. 

Histologically,  the  wall  of  serous  cysts,  as  of  pseudomucinous  cysts, 
is  composed  of  three  layers,  differing  only  in  the  inner  layer  which  is 
lined  by  columnar  ciliated  cells.  The  papillary  growths  often  present 
on  microscopical  section  the  most  picturesque  forms,  usually  consist- 
ing of  rather  scant  connective-tissue  stalks  with  branching  processes 
extending  in  every  direction  from  the  main  trunk  (Fig.  259).  The  epi- 
thelium covering  the  papillary  growths  is  the  same  as  that  lining  the 
cyst.  Not  infrequently,  deposits  of  lime  salts  are  to  be  seen  in  the 
papillomatous  growths,  often  presenting  a  concentric  layer  arrange- 
ment; they  are  termed  psammoma. 

Superficial  Papilloma  of  the  Ovary. — Occasionally,  noncystic  ovaries 


Fig.  258. — "  Serous  cysts  are  encountered  with  papillary 
growths  on  their  surface." — Eothrock. 


NEOPLASMS  OF   THE   OVARIES 


609 


are  covered  with  papillomatous  growths,  which  are  similar  in  their 
gross  appearances  and  anatomic  structure  to  those  found  in  cysts. 
Frequently,  they  completely  cover  the  ovary,  so  that  it  appears  as  a 
papillomatous  mass  which  may 
reach  the  size  of  an  orange.  These 
growths  may  originate  from  per- 
foration of  small  cysts  which  be- 
come filled  with  papillomatous 
growths  and  afterward  spread  over 
the  surface  of  the  ovary;  or  they 
may  grow  directly  from  the  ger- 
minal epithelium,  which  is  perhaps 
the  more  common  mode  of  origin. 
They  are  frequently  bilateral,  or 
may  occur  in  company  with  a  papil- 
lomatous cyst  of  the  other  ovary. 
Histologically,  their  structure  does 
not  differ  from  that  of  papillary 
growths  occurring  in  cysts.  They 
are  invariably  covered  with  ciliated 
ei^ithelium. 

Histogenesis.  —  The  origin  of 
proliferating  cysts  of  the  ovary  is 
still  a  matter  of  much  controversy, 
although  the  investigations  of 
many  competent  observers  in  re- 
cent years,  have  done  much  to 
throw  light  upon  this  obscure  sub- 
ject. Formerly  all  ovarian  cysts 
were  believed  to  originate  in  the 
Graafian  follicle.  Virchow,  after 
•a  careful  investigation  of  colloid 
cysts,  concluded  that  they  were  of 
connective-tissue  origin,  the  result 
of  colloid  degeneration  of  the  stroma  of  the  ovary,  and  that  the  colloid 
mass  constituting  the  cyst  contents  was  the  product  of  degeneration. 

The  excellent  work  of  Klebs  and  Waldeyer  in  determining  the 
epithelial  origin  of  cysts,  has  placed  the  subject  of  histogenesis  on  a 
firm  basis.  They  advanced  the  theory  that  proliferating  cysts  origi- 
nated from  Pfliiger's  tubes.  More  recent  investigations  have  shown, 
however,  that  epithelial  neoplasms  have  their  origin,  not  in  the  em- 
bryonal Pfliiger's  tubes,  but  in  tube  or  glandlike  formations  occasioned 
by  a  tilting  in,  and  subsequent  invagination  of,  the  germinal  epi- 
thelium into  the  ovarian  stroma,  which  from  the  beginning  must  be 
regarded  as  neoplasms.  According  to  Pfannenstiel,  this  dipping  in  of 
the  germinal  opitholium  is  not  to  be  considered  in  the  same  light  with 
embryonal  misplaced  epithelium  in  the  sense  of  Cohnbcim's  theory, 
40 


Fig.  259  (Whitacee).  —  "The  papillary- 
growths  often  present  on  microscopical 
section  the  most  picturesque  forms." 
—  EoTHEOcK  (page  608). 


^IQ  A  TEXT-BOOK  OF   GYNECOLOGY 

but  rather  as  the  result  of  certain  pathologic  changes  which  the  ger- 
minal epithelium  undergoes.  Until  comparatively  recently,  the  ger- 
minal epithelium  was  considered  the  sole  source  of  proliferating  cysts, 
but  evidence  begins  to  accumulate  that  they  may,  and  often  do,  origi- 
nate in  the  Graaffian  follicle. 

The  careful  researches  of  Flaischlen,  Bulius,  Steffeck,  Frommel, 
Pfannenstiel,  Williams  and  others,  seem  to  prove  beyond  doubt,  that 
under  certain  conditions  the  membrana  granulosa  of  the  follicle  may 
undergo  pathologic  change  and  be  replaced  by  cylindrical  epithelium, 
from  which  cysts  may  develop  in  a  manner  analogous  to  those  devel- 
oping from  the  germinal  epithelium.  Williams,  after  an  exhaustive 
study  of  the  histogenesis  of  papillary  cysts,  concludes:  (1)  that  the 
Graafian  follicle  is  probably  the  usual  starting  point  of  papillary  cysts, 
and,  according  as  the  membrana  granulosa  is  transformed  into  cili- 
ated epithelium  or  not,  so  will  the  cyst  be  lined  with  ciliated  or  non- 
ciliated  epithelium.  (2)  That  the  germinal  epithelium  is  perhaps  the 
most  frequent  source  of  superficial  and  multilocular  papillary  cysts. 

On  the  other  hand,  Pfannenstiel  has  shown  that  serous  or  ciliated 
cysts  may  develop  from  the  germinal  epithelium,  it  having  first  under- 
gone pathologic  change,  becoming  ciliated ;  and  he  regards  this  as  the 
usual  orgin  of  such  cysts,  while  von  Velits  entertains  the  view  that 
most  ciliated  cysts  have  their  origin  in  the  Graafian  follicle. 

According  to  Pfannenstiel,  pseudomucinous  cysts  usually  originate 
in  the  Graafian  follicle. 

The  theory  advanced  by  Marchand,  that  ciliated  cysts  may  origi- 
nate from  tubal  epithelium,  still  remains  to  be  proved.  To  sum- 
marize, therefore,  it  may  be  said  that  both  pseudomucinous  and 
serous  cysts  may  have  their  origin  in  the  germinal  epithelium  or  in  the 
Graafian  follicle. 

Metastasis. — Both  varieties  of  proliferating  cysts  may  give  rise  to 
metastasis.  While  pseudomucinous  cysts  are  usually  classed  with  be- 
nign tumours,  occasionally  metastases  have  been  observed,  especially 
occurring  in  the  peritoneum,  which  must  be  regarded  as  implantation 
metastases.  They  have  most  frequently  been  noted  in  cysts  with 
papillary  growths,  and  they  tend  to  develop  underneath  the  peri- 
toneum in  the  form  of  cystic  growths  containing  gelatinous  masses, 
and  have  been  termed  pseudomyxoma  peritonei  (Werth).  They  most 
frequently  follow  spontaneous  rupture  of  cysts,  thus  allowing  the  cyst 
contents  to  escape  into  the  peritoneal  cavity,  though  they  have  been 
observed  to  follow  operation  for  the  removal  of  cysts,  when  they  must 
be  regarded  as  implantations  occurring  at  the  time  of  operation. 

Various  explanations  have  been  advanced  in  explanation  of  im- 
plantation metastasis,  but  it  is  generally  believed  that  it  takes  place 
at  points  where,  from  irritation,  as  from  pressure  or  operative  pro- 
cedures, the  endothelial  lining  of  the  peritoneum  has  been  destroyed. 
These  metastases  are  possessed  of  no  special  degree  of  malignancy, 
but  are  particularly  prone  to  recur  after  removal. 


NEOPLASMS  OF   THE   OVARIES  611 

Metastasis  is  much  more  frequently  observed  to  follow  serous  cysts. 
The  glandular  form  is  benign  and  does  not  tend  to  recur  after  removal 
or  to  give  rise  to  metastasis.  The  papillary  form,  however,  is  particu- 
larly characterized  by  the  tendency  to  metastasis  which  occurs,  accord- 
ing to  Pfannenstiel,  in  the  proportion  of  about  13.3  per  cent.  Metas- 
tases almost  invariably  occur  in  the  peritoneum,  and  appear  as 
superficial  cauliflower  growths.  They  are  very  persistent,  and  only 
complete  and  thorough  removal  by  radical  operation  will  effect  a  cure. 

Malignant  Degeneration. — Both  varieties  of  ovarian  cysts  may  un- 
dergo malignant  degeneration.  From  the  epithelial  elements,  carci- 
noma may  have  its  origin,  while  sarcoma  may  begin  in  the  connective 
tissue  of  the  wall  of  the  cyst.  A  cyst  can  only  be  said  to  have  under- 
gone carcinomatous  degeneration  when  the  carcinoma  is  localized  in 
small  areas  while  the  remainder  of  the  tumour  presents  no  evidence 
of  malignancy.  In  case  the  carcinomatous  process  is  widespread,  the 
tumour  must  be  classed  as  primarily  carcinoma.  (See  Carcinoma  of 
the  Ovary.) 

Sarcomatous  degeneration  of  the  wall  of  ovarian  cysts  has  been 
only  rarely  observed.  Cases  have  been  reported  by  Pfannenstiel,  E. 
Frankel  and  Kelly.  It  may  occur  in  the  form  of  a  nodule  or  as  a  dif- 
fuse infiltration  of  a  considerable  area  of  the  cyst  wall. 

Dermoid  cysts,  as  the  name  implies,  are  tumours  containing  struc- 
tures resembling  skin.  They  are  the  least  frequent  of  ovarian  cysts, 
occurring,  according  to  Olshausen,  in  the  proportion  of  about  3.5  per 
cent.  They  are  usually  small,  seldom  reaching  a  size  larger  than  a 
man's  head.  They  are  commonly  unilateral,  though  bilateral  tumours 
are  by  no  means  infrequent.  Gebhard,  among  107  cases,  found  16 
bilateral.  In  most  instances,  they  present  a  smooth  external  surface, 
though  they  may  be  irregular  in  outline  and  be  attached  to  the  sur- 
rounding structures  by  adhesions.  Generally  they  are  attached  by  a  well- 
formed  pedicle,  and  only  rarely  do  they  develop  within  the  folds  of  the 
broad  ligament.  In  the  majority  of  instances,  they  appear  as  simple 
cysts,  though  close  examination  will  frequently  reveal  the  remains  of 
septa  or  small  cysts  within  the  tumour  walls. 

The  cyst  contents  vary  in  consistence.  In  pure  dermoid  cysts  they 
consist  of  an  oily  fatty  substance,  frequently  resembling  vernix  caseosa, 
which  thickens  on  cooling.  It  often  contains  loose  hair,  which  is 
usually  rolled  in  balls,  besides  caseous  masses  that  are  accumulations 
of  sebaceous  matter  (Fig.  260). 

On  section,  a  typical  dermoid  cyst  is  unilocular.  More  frequently, 
however,  dermoid  cysts  are  combined  with  proliferating  cysts  in  which 
one  or  more  of  the  cyst  cavities  contain  dermoid  structures.  Accord- 
ing to  Pfannenstiel  (Veit's  Handbucli,  vol.  iii,  p.  366),  they  are  most 
frequently  combined  with  pseudomucinous  cysts,  and  very  rarely  with 
serous  papillary  cysts. 

The  outer  layer  of  the  cyst  wall  is  fibrous  and  usually  thin,  while 
the  inner  layer  consists  of  a  structure  )-esembling  skin,  from  which 


gl2  A   TEXT-BOOK  OP  GYNECOLOGY 

are  frequently  found  growing  appendages  of  the  skin,  as  hair,  teeth, 
occasionally  nails;  and  in  them  are  developed  sweat  and  sebaceous 
glands  (Fig.  261). 

Between  this  layer  and  the  outer  cyst  wall,  is  usually  found  a  struc- 
ture resembling  adipose  tissue,  which  consists  largely  of  fat  and  con- 


FiG.  260. — "It  often  contains  loose  hair  .  .  .  besides  caseous  masses." — Eotheock  (page  611.) 

nective  tissue;  in  it  are  often  found  bone,  smooth  muscle,  more  rarely 
nervous  tissue,  cartilage,  and,  in  a  few  instances,  glandular  structures 
resembling  the  mammary  and  thyroid  glands  have  been  observed.  Very 
rarely,  structures  corresponding  to  the  intestinal  or  respiratory  tract 
have  been  observed.  In  these  structures,  Wilms  has  recognised  an 
attempt  at  reproduction  of  the  three  embryonal  layers — namely,  those 
growing  from  the  ectoderm  including  skin  and  appendages;  those 
from  the  mesoderm  consisting  of  fat,  connective  tissue,  bone,  muscle 
and  nervous  tissue;  and  endodermal  structures  resembling  intestines 
and  respiratory  tract. 

As  a  rule,  dermoid  structures  are  found  only  in  a  small  area  of 
the  cyst  wall  appearing  as  a  nodular  raised  prominence,  which  is 
covered  with  hair  and  may  contain  teeth  or  bone.  The  hair  in  der- 
moid cysts  is  as  a  rule  short,  though  it  may,  rarely,  reach  a  length  of 
several  feet.  It  is  usually  of  a  reddish  brown  or  blonde  colour,  which 
is  uniform  throughout  the  cyst.  Teeth  are  usually  irregularly  shaped, 
often  rudimentary,  and  as  a  rule  only  a  few  are  present,  though  as 
many  as  300  have  been  reported.  They  are  generally  incisors  or  molars, 
and  are  set  with  their  crowns  pointing  toward  the  axis  of  the  body. 
ISTot  infrequently,  they  are  set  in  bone  resembling  rudimentary  jaws. 
The  bones  found  in  dermoid  cysts  simulate  those  which  lie  in  positions 
near  hair-covered  skin,  as  the  maxillary  bones,  bones  of  the  cranium. 


NEOPLASMS  OF   THE   OVARIES 


613 


or  pubic  bones.  Less  frequently,  bones  resembling  long  bones  have 
been  observed,  such  as  ribs,  phalanges  of  fingers  or  toes,  and  even  joint- 
like formations  with  cartilaginous  covering  have  been  described. 
Earely,  brainlike  formations  have  been  observed,  and  in  a  few  instances, 
also,  structures  simulating  the  eye,  with  retinal  pigment. 

Histologically,  dermoids  are  of  the  greatest  interest  from  the  won- 
derful variety  of  structures  they  contain.  Almost  every  tissue  or  organ 
in  the  body  may  find  its  prototype  in  the  structures  of  a  dermoid 
cyst,  though  often,  it  is  true,  in  a  more  or  less  rudimentary  state. 

Until  comparatively  recently,  the  theory  most  generally  accepted  in 
explanation  of  the  origin  of  dermoids,  was  that  of  inclusion.  At  the 
present  time,  the  ovulogenous  theory,  proposed  by  Wilms,  finds  most 
adherents.  In  proof  of  its  correctness,  there  has  been  advanced  the 
finding  of  structures  in  dermoids,   corresponding  to   the   three   em- 


FiG.  261  fGEBHARrj). — "In  them  are  developed  sweat  and  sebaceous  glands." — Rothrock 

(page  612). 


bryonal  layers,  which  is  characteristic  of  ovarian  dermoids  alone,  as 
compared  with  those  occurring  in  other  regions  of  the  body.  In  further 
support  of  this  theory,  the  fact  that  they  are  sometimes  met  with 
in  the  foetus  makes  it  appear  that  they  have  their  beginning  in  early 
life,  and  that  the  ovum  possesses  all  the  requisites  necessary  for  the  de- 
velopment of  the  many  structures  present  in  dermoid  cysts. 


614 


A   TEXT-BOOK   OF   GYNECOLOGY 


Malignant  Degeneration. — Dermoid  cysts  may  undergo  sarcomatous 
or  carcinomatous  degeneration  (Fig.  263).  Sarcoma  usually  develops  in 
the  wall  of  the  cyst. 

Well-authenticated  carcinoma  beginning  in  dermoids  has  been  ob- 
served in  a  few  instances.    It  was  formerly  believed  that  it  was  always 

epidermal  in  charac- 
ter. Eecently,  how- 
ever, Yamigiva  found 
a  glandular  carci- 
noma which  he  be- 
lieved to  have  origi- 
nated in  a  pseudo- 
mammary  gland. 

Teratoma. — Tera- 
tomata  are  tumours 
closely  related  to  der- 
moids in  their  his- 
togenesis, but  differ- 
ing in  their  struc- 
ture and  appearance. 
They  are  very  rare, 
as  comjDared  with 
dermoids,  and  are 
solid  tumours,  or  are 
at  least  made  up 
largely  of  solid  struc- 
tures. They  are  usu- 
ally unilateral  and  may  reach  enormous  size.  The  tumour  consists  of  a 
conglomeration  of  embryonal  elements  resting  on  a  fibrous  structure, 
or  stroma,  which  is  rich  in  blood  vessels.  They  are  inclosed  in  a 
fibrous  capsule,  in  which  may,  at  times,  be  found  the  remains  of 
ovarian  stroma.  Histologically,  they  contain  the  same  embryological 
elements  as  dermoids. 

Solid  Tumours. — Fibroma  of  the  Ovary. — Fibroma  belongs  to  the 
rarer  ovarian  tumours,  its  frequency  being,  according  to  the  estimate 
of  Pfannenstiel,  between  2  and  3  per  cent.  It  is  probable  that  a  num- 
ber of  tumours  heretofore  described  as  fibroma  were  in  reality  fibro- 
sarcoma. 

As  a  rule,  their  surface  is  smooth,  though  often  irregular  in  outline, 
and  they  are  usually  attached  by  a  pedicle,  but  may  develop  within  the 
ligament  (Fig.  263).  They  are  usually  unilateral,  though  they  may  be 
bilateral.  In  size,  they  vary  from  that  of  a  walnut  to  that  of  a  man's 
head,  and  may  rarely  weigh  as  much  as  30  or  40  pounds.  Usually  no 
ovarian  structure  can  be  recognised.  They  vary  in  consistence.  When 
the  tumour  consists  of  pure  fibroma  it  is  firm.  Occasionally,  the  tumour 
may  be  cystic  from  the  presence  of  dilated  lymph  or  blood  vessels,  or 
cystic  cavities  may  result  from  degeneration  or  necrosis. 


Fig.  262. — "Dermoid  cysts  may  underoo  . 
degeneration." — Kothkoc  k 


carcinomatous 


NEOPLASMS  OF  THE  OVARIES 


<;i5 


Fibroid  tumours  of  the  ovary  may  undergo  fatty  or  myxomatous  de- 
generation, or  contain  calcareous  deposits. 

Histologically,   they  are   composed   of   fibrillary   connective-tissue 
bundles  which  run  in  all  directions,  and  smooth  muscle  fibres  may 
be  present,  though  as  a 
rule     they     are     scanty 
(Fig.  264). 

Earely,  combinations 
with  other  tumours  are 
observed,  as  with  ade- 
noma and  sarcoma,  and 
the  former  may  degener- 
ate into  carcinoma  or 
develop  cystic  cavities 
containing  colloid  sub- 
stance. When  smooth 
muscle  is  present,  the 
tumour  is  properly 
termed  fibromyoma.  A 
few  cases  of  pure  myoma 
of  the  ovary  have  been 
described,  but  they  are 
very  rare. 

Calcified  tumours  of 
the  ovary  have  been  ob- 
served from  time  to 
time;  they  have  general- 
ly been  regarded  as  oste- 
omata,  but  the  careful 
investigations  of  Whit- 
ridge  Williams  have  established  the  fact  that  they  contain  no  bony 
tissue.  Schlenker  published  a  description  of  this  condition  about  the 
middle  of  the  eighteenth  century,  and  was  followed  a  few  years  later 
(1760)  by  Le  Clerc  de  Beaucoudray,  with  a  description  of  an  ossified 
ovary.  From  that  time  until  the  present,  numerous  similar  descriptions 
have  appeared,  all  of  them  obviously  based  upon  the  original  miscon- 
ception as  to  the  true  character  of  the  growth.  The  process  of  calcifica- 
tion may  (a)  occur  in  the  ovarian  stroma;  or  (&)  be  restricted  to  the 
Graafian  follicle. 

Calcareous  Tumours  of  tlie  Ovarian  Stroma. — These  growths,  if 
such  they  may  be  called,  are  generally  small,  the  ovary  containing  them 
rarely  exceeding  7  centimetres  in  its  longest  diameter.  In  one  case 
examined  by  Williams  the  ovary  revealed  many  cicatrices,  but  no 
adhesions,  upon  its  surface.  On  section,  one  end  was  found  to  be  occu- 
pied by  a  hard  roundish  nodule  12,  16,  and  18  millimetres  in  its  various 
diameters  (Fig.  265).  This  nodule  occupied  an  apparent  capsule  with 
which  it  was  connected  by  numerous   connective-tissue  bands.     On 


Fig.  263  (Maetin). — "  As  a  rule,  their  surface  is  smooth, 
though  often  irregular." — Kotheock  (page  614). 


616 


A   TEXT-BOOK  OF   GYNECOLOGY 


Fig.  264  (Whitacre). — "  They  are  composed 
of  fibrillary  connective  -  tissue  bundles 
which  run  in  all  directions." — Rotheock 
(page  615). 


sawing  through  the  nodule^  which  was  of  bony  hardness,  its  cut  sur- 
face presented  a  mottled  appearance  and  the  general  colour  of  bone. 
At  one  side  of  the  ovary  were  found  the  corrugated  walls  of  an  old 
corj)us  luteum,  about  13  millimetres  in  diameter.    Here  and  there  were 

seen  several  follicles  with  clotted 
contents.  On  the  other  side,  the 
ovary  revealed  a  hard  large  nod- 
ule measuring  7,  6,  and  5  centi- 
metres in  its  various  diameters. 
From  the  anterior  and  inner  sur- 
face of  the  ovary  there  developed 
a  number  of  small  pedunculated 
fibromata,  the  largest  being  6 
millimetres  in  diameter.  From 
the  neighbourhood  of  these  small 
fibromata,  the  ovarian  tissue  cov- 
ering the  hard  nodule  began  to 
decrease  in  thickness,  soon  be- 
coming as  thin  as  a  sheet  of  pa- 
per. This  thin  capsule  was  per- 
forated in  a  number  of  places, 
through  which  perforations  the 
surface  of  the  hard  mass  was  visi- 
ble. This  mass  weighed  220  grammes,  was  extremely  hard,  and  re- 
sembled ivory  in  its  general  consistence.  When  thrown  upon  a  hard 
surface  it  rebounded  like  a  billiard  ball.  On  section,  its  surface  was 
mottled,  presenting  an  appearance  similar  to  that  of  the  smaller  nodules 
of  the  other  ovaries. 
Dry  sections  of  both 
masses  revealed  no 
trace  of  bony  struc- 
ture. Microscopical 
sections  made  after 
decalcification  by  a 
10-per-cent  solution 
of  nitric  acid, 
showed  that  both 
masses  were  iden- 
tical in  structure. 
They  were  composed 
of  typical  fibrous  tis- 
sue made  up  of  bun- 
dles of  dense  connective  tisuse,  which  interlaced  in  all  directions,  and 
possessed  but  few  long  nuclei.  The  tissue  resembled  that  found  in  the 
hilum  of  the  ovary,  except  that  it  was  poorer  in  blood  vessels,  and  con- 
tained more  veins  than  arteries.  Scattered  all  through  it,  were  irregu- 
lar-shaped areas  of  various  size,  which  stained  deeply  with  hematoxylin. 


Fig.  265. — "  On  section,  one  end  was  found  to  be  occupied  by 
a  hard  roundish  nodule."— Keed  (page  615). 


NEOPLASMS  OP   THE   OVARIES  617 

They  generally  presented  sharply  marked  contours,  and,  in  their  in- 
terior, revealed  signs  of  striation,  but  no  trace  of  nuclei  could  be  found 
within  them.  Here  and  there,  under  a  high  power,  could  be  seen 
individual  cells  which  had  lost  their  nuclei  and  presented  the  typical 
appearance  of  coagulation  necrosis.  Single  cells,  each  containing  a 
calcareous  granule,  and  others  which  were  entirely  calcified,  were  ob- 
served. The  general  mass  had  manifestly  developed  by  a  process  of 
cell  coalescence. 

Calcareous  tumours  of  the  corpus  luteum  have  been  observed  by 
Bland  Sutton,  Coe  and  others.  Coe's  case  was  examined  and  reported 
upon  by  Whitridge  Williams  substantially  as  follows:  The  ovary  was 
5  centimetres  long  and  2.5  centimetres  deep;  on  its  surface  were 
numerous  cicatrices  but  no  adhesions;  in  its  centre  was  a  hard  mass 
13  millimetres  in  diameter,  of  bonelike  consistence.  When  sawn 
through,  it  was  seen  to  consist  of  two  portions,  a  soft  pinkish  central 
portion,  and  a  hard  bonelike  outer  portion,  2  millimetres  thick,  and 
of  a  distinctly  yellow  colour.  The  central  portion  of  the  nodule  re- 
sembled partially  organized  blood  clot.  The  rest  of  the  ovary  presented 
a  normal  appearance.  Microscopic  examination  after  decalcification 
and  section  of  the  mass,  revealed  no  signs  of  osseous  structure.  The 
decalcified  sections  stained  poorly,  but  the  hard  exterior  of  the  nodule 
stained  readily  with  hematoxylin  and  presented  a  more  or  less  homo- 
geneous granular  appearance,  in  which  it  was  impossible  to  distinguish 
nuclei.  This  tissue  was  surrounded  by  typical  ovarian  stroma,  which 
also  stained  poorly.  The  central  portion  of  the  nodule  was  composed 
of  dense  fibrous  tissue  which  was  very  poor  in  cells.  Between  this  and 
the  decalcified  portion,  were  layers  of  small  cells,  possibly  corresponding 
to  the  membrana  granulosa,  though  it  is  impossible  to  state  their  origin 
with  certainty.  In  the  surrounding  ovarian  stroma  were  numerous 
round  stellate  crystals,  which  were  thought  to  be  the  result  of  the 
decalcification.  The  specimen  was  looked  upon  by  Williams  as  in  all 
probability  representing  a  calcification  of  the  large  cells  which  sur- 
round a  ripe  G-raafian  follicle  and  form  the  yellow  margin  of  the 
corpus  luteum. 

The  causes  of  calcification  within  the  ovary  probably  do  not  differ 
in  general  from  those  producing  that  condition  in  other  parts  of  the 
body.  The  deposit  of  calcareous  salts,  first,  in  foci  which,  coalescing, 
form  the  larger  masses,  is  recognised  b}^  Cohnheim,  Litten,  and  Whit- 
ridge Williams,  as  following  only  certain  varieties  of  necrosis,  par- 
ticularly those  characterized  by  coagulation.  The  calcification  of  ne- 
crotic areas  is  explained  by  the  chemical  affinity  which  exists  between 
the  necrotic  tissue  and  the  calcium  salts  circulating  in  the  blood,  prob- 
ably as  a  soluble  albuminate.  It  is  assumed  that  the  soluble  albumi- 
nate, by  virtue  of  chemical  affinity,  mingles  with  the  material  of  the 
dead  cells  forming  an  insoluble  albuminate  of  lime  which  is  deposited 
in  them.  That  this  general  law  of  calcification  is  operative  within  the 
ovary,  becomes  apparent  when  it  is  remembered  that  that  organ  is  liable 


QIS  '        A   TEXT-BOOK   OF   GYNECOLOGY 

to  fibroid  changes,  to  displacements,  and  to  other  mechanical  interfer- 
ence with  its  circulation,  all  of  them  calculated  to  induce  more  or  less 
cell  necrosis. 

The  symptoms  of  calcareous  tumours  of  the  ovary  are  in  no  sense 
characteristic.  The  diagnosis  of  this  condition  has  probably  never  been 
made  before  operation.  There  is,  therefore,  no  special  treatment,  other 
than  that  which  applies  to  other  solid  tumours  of  the  ovaries.  When 
discovered  they  should  be  removed.     (See  Ovariotomy.) 

Hematoma  of  the  Ovaries. — Follicular  hemorrhage  is  of  common 
occurrence,  being  due  to  the  rupture  of  vessels  in  the  wall  of  the 
ovisac.  But  the  term  hematoma  is  usually  applied  clinically  to 
tumours  above  the  size  of  a  hazelnut.  In  the  case  of  hemorrhage  into 
a  follicular  cyst,  they  may  reach  the  size  of  a  small  orange.  While 
excessive  hypergemia  of  the  ovary  may  lead  to  interstitial  hemorrhage, 
so-called  apoplexy  of  the  gland  is  probably  always  secondary  to  rup- 
ture of  a  follicular  hematoma. 

Causes  and  Pathology. — Venous  stasis  leading  to  the  rupture  of 
veins  in  the  walls  of  dropsical  follicles  may  be  due  to  pelvic  conges- 
tion from  any  cause,  such  as  sexual  excitement  or  excess.  Its  occur- 
rence in  connection  with  neoplasms,  ectoiDic  gestation,  and  abortion, 
is  similarly  explained.  Hematoma  is  often  associated  with  tubal  dis- 
ease, especially  when  there  are  many  adhesions  or  torsions  of  the 
pedicle.  General  follicular  hemorrhage  and  apoplexy  have  been  noted 
as  the  result  of  profound  alteration  of  the  blood  in  extensive  burns, 
phosphorus  poisoning,  and  in  the  acute  exanthemata.  An  ovary 
which  is  the  seat  of  general  follicular  hemorrhage,  is  enlarged  to  two 
or  three  times  its  normal  size,  dark  red  nodules  as  large  as  a  pea  or 
marble  appearing  on  its  surface.  On  section,  these  are  seen  to  be  cir- 
cumscribed collections  of  semifluid  blood  or  coagula  in  various  stages 
of  absorption.  Or  a  single  tumour  may  include  almost  the  entire 
ovary,  only  a  small  portion  of  the  stroma  remaining.  The  usual 
changes  occur  in  the  blood  until  only  a  clot  or  mass  of  fibrin  is  found. 
The  cyst  may  become  infected  through  its  proximity  to  the  gut  or 
Fallopian  tube.  The  internal  pressure  may  become  so  great  that  it 
ruptures,  and  an  intraperitoneal  hematocele  develops;  but  it  is  doubt- 
ful if  sufficient  blood  ever  escapes  to  endanger  life. 

Symptoms  and  Diagnosis. — In  spite  of  the  statements  in  text- 
books, it  is  questionable  if  the  symptoms  of  ovarian  hematoma  are  suf- 
ficiently characteristic  to  warrant  a  positive  diagnosis;  in  fact,  the 
condition  is  usually  found  on  opening  the  abdomen  for  supposed  in- 
flammatory disease.  The  sudden  occurrence  of  severe  throbbing  pain 
in  the  region  of  the  ovary,  with  marked  enlargement  and  tenderness, 
but  without  rise  of  temperature,  in  connection  with  conditions  leading 
to  excessive  pelvic  congestion,  would  point  to  a  rapid  effusion  of  blood 
into  a  follicle.  The  sudden  enlargement  of  a  pre-existing  cystic  ovary 
would  be  still  more  significant.  Should  the  cyst  rupture,  the  usual 
symptoms   of  intraperitoneal  hemorrhage   would   develop,   though  it 


NEOPLASMS   OP   THE   OVARIES  619 

would  be  exceedingly  difficult  to  diagnosticate  it  from  early  rupture 
of  an  ectopic  sac.  After  the  acute  stage,  or  in  cases  of  slow  oozing, 
the  symptoms  are  those  common  to  ovarian  disease,  and  are  often 
masked  by  those  of  localized  peritonitis. 

Treatment. — The  treatment  of  acute  hemorrhage  consists  in  rest, 
ice-bags,  low  diet,  regulation  of  the  bowels,  and  the  avoidance  of  any 
influences  tending  to  increase  pelvic  .congestion.  True  hematoma  of 
the  ovary  is  a  surgical  condition,  and  calls  for  removal  of  the  affected 
ovary,  or  of  the  blood  sac  alone  if  a  portion  of  healthy  stroma  can 
be  preserved. 

Malignant  Neoplasms 

Primary  carcinoma  of  the  ovary  is  the  most  common  form  of  ma- 
lignant disease  of  the  ovary.  While  varying  greatly  in  form  and 
appearance,  it  admits  of  division  into  two  groups,  each  of  which  is 
represented  by  a  more  or  less  distinct  type. 

Group  I.  Medullary  Carcinoma. — The  first  group  consists  of  solid 
tumours.  They  are  of  more  or  less  firm  consistence,  usually  rounded 
or  oval  in  shape,  though  often  irregular  in  outline,  and  frequently 
present  a  nodular  or  lobulated  appearance.  They  vary  in  size,  rarely, 
however,  exceeding  that  of  the  head  of  a  newborn  child.  As  a  rule 
they  form  their  attachment  by  a  short  thick  pedicle,  and  usually  they 
lie  free  in  the  abdominal  cavity;  only  very  rarely  have  tumours  been 
observed  which  were  partially  intraligamentary.  JSTot  infrequently, 
they  are  bilateral  though  unilateral  development  is  the  rule. 

They  are  inclosed  in  a  dense  fibrous  capsule,  and,  on  section,  pre- 
sent a  more  or  less  homogeneous  surface  of  yellowish  or  gray  white 
colour  (Fig.  266).  Frequently,  in  softer  tumours,  the  appearance  is 
brainlike.  Occasionally,  the  tumour  will 
have  a  mottled  appearance  from  extravasa- 
tions of  blood  into  the  tumour  substance, 
which,  if  recent,  may  be  coagulated,  or  if 
of  long  standing,  may  appear  as  an  extrav- 
asation cyst  simulating  those  often  foimd 
in  cerebral  hemorrhage.  Degeneration 
changes  are  of  common  occurrence,  espe- 
cially caseous  and  fatty  changes,  with  re- 
sulting softening  and  the  formation  of 
cystlike   cavities.      The   contents   of   such 

■^    ,  ,      1  -n  IP  m        •  1  1  Fig.  266  (Gebhard).—"  They  are 

cysts  are  turbid  and  of  a  yellowish  colour,         .^^^j^^^^  -^  ^  ^^^^^^^  ^^^^^^  ^^p. 
while  their  walls  present  an  irregular  and         suie."— Eothrock. 
uneven  outline.     Histologically,  they  are 

composed  of  a  more  or  less  diffuse  infiltration  of  a  fibrous  stroma  with 
carcinomatous  cells.  In  some  instances,  the  fibrous  stroma  predomi- 
nates, forming  alveoli  which  are  filled  with  carcinomatous  cells.  More 
frequently,  however,  the  microscopic  appearance  is  that  of  a  diffuse* 
infiltration  of  the  rather  sparse  fibrous  stroma,  so  that  the  cellular  ele- 


620 


A  TEXT-BOOK  OF   GYNECOLOGY 


nient  constitutes  the  greater  part  of  the  tumour,  in  which  case  it  is 
termed  medullary  carcinoma. 

Group  II.  Adenocarcinoma. — The  second  group  consists  of  cystic 
tumours  which  bear  a  striking  resemblance  in  their  external  appear- 
ance to  serous  cysts.  They  are  rounded  or  oval  tumours,  and  rarely 
exceed  in  size  an  adult's  head,  being  usually  smaller.  They  are  gen- 
erally attached  by  a  short  pedicle,  though  they  may  develop  within  the 
ligament,  and  are  frequently  adherent  to  the  surrounding  viscera. 
Like  serous  cysts,  they  are  often  bilateral  and  are  usually  multilocular, 
though  they  may  at  times  appear  unilocular. 

According  to  Pfannenstiel,  papillary  growths  are  observed  on  the 
external  surface  of  the  cyst  in  about  half  the  cases.  On  section,  the 
cyst  wall  is  composed  of  connective  tissue  which  is  often  quite  friable. 
Frequently  the  wall  of  the  cyst  is  very  much  thickened  in  spots  from 
the  development  in  it  of  carcinomatous  nodules.  Growing  from  the 
internal  surface,  may  usually  be  seen  papillary  and  cauliflower  growths 
at  times  almost  filling  the  cyst  cavity.  The  cyst  contents  may  be 
clear,  but  more  frequently  they  are  turbid  from  the  presence  of  cellu- 
lar elements,  or  they  may  be  blood-tinged  from  hemorrhage  into  the 


Fig.  267. — "  Cystic  carcinoma  of  the  ovary  is  almost  invariably  papillary." — Kotheock. 


cyst.  Cystic  carcinoma  of  the  ovary  is  almost  invariably  papillary 
(Fig.  267).  The  papillary  growths  are  often  similar  in  appearance  to 
those  of  the  papillary  cysts,  still,  on  section,  their  carcinomatous  nature 
may  often  be  recognised  by  the  naked  eye. 

Histologically,  they  belong  to  the  adenocarcinomata,  and  often  the 
same  tumour  presents  a  great  variety  of  structure.     The  solid  masses, 


NEOPLASMS  OF   THE  OVARIES 


621 


which  are  found  in  the  wall  of  the  cyst,  may  consist  of  a  diffuse  infil- 
tration of  a  medullary  character.  More  frequently,  however,  such 
nodules  and  cauliflower  growths  are  not  really  solid  but  are  made  up 
of  papilla  and  glandhke  formations,  the  lumen  of  which  is  still  plainly 
visible.  Everywhere  an  atypical  proliferation  of  epithehal  cells  is 
present,  and  in  papillary  growths,  instead  of  being  covered  with  a 
single  layer  of  cells  as 
in  cystadenoma,  the  epi- 
thelium will  be  replaced 
by  several  layers  of  cells 
asymmetrically  arranged 
(Pig.  268).  The  same 
peculiarity  is  observed  in 
the  glandlike  formations 
in  which,  instead  of  be- 
ing lined  with  a  single 
layer  of  cells,  the  lumen 
will  frequently  be  filled 
with  a  iDroliferation  of 
cells  giving  it  an  alve- 
olar appearance. 

Not  infrequently, 
lime  salts  become  depos- 
ited, especially  in  the 
papillary  growths,  with 
the  formation  of  psam- 
moma.  Between  cystad- 
enoma (Fig.  269)  and  this  type  of  primary  carcinoma,  every  gTadation 
exists,  and  so  gradual  is  the  transition  that  it  is  not  always  possible  to 
distinguish  between  them.  Ziegler  {Pathologisclie  Anatomie,  page  335) 
admits  that  no  sharp  dividing  line  can  be  drawn  between  adenomata 
which  are  benign  and  those  which  are  malignant. 

Pfannenstiel  estimates  that  fully  one  half  of  all  papillary  tumours 
of  the  ovary  belong  to  the  carcinomata,  but,  according  to  his  view, 
almost  all  cases  which  ultimately  become  carcinomatous  should  be 
classed  as  primary  carcinoma.  The  adenoma  from  which  the  carci- 
noma develops,  he  regards  as  representing  an  intermediary  stage,  but 
at  the  same  time  he  admits  that  there  is  no  means  of  distinguishing 
it  from  benign  adenoma.  Most  authors,  however,  take  a  middle 
ground,  and  regard  a  considerable  number  of  such  tumours  as  carcino- 
matous degeneration  of  primary  benign  tumours. 

The  microscopic  evidence  of  malignant  change  consists  in  a  pro- 
liferation of  the  epithelial  cells  with  atypical  arrangement,  as,  for 
example,  instead  of  the  uniform  single  layer  of  epithelium  are  to  be 
seen  masses  of  cells,  asymmetrical  in  their  arrangement,  and  tending 
to  form  several  layers  (Fig.  270). 

Metastasis  is  of  frequent  occurrence,  tending  to  involve  first  of 


Fig.  268  (Whitacee). — "  Every  where  an  atypical  prolif- 
eration of  epithelial  cells  is  present." — Eothbock. 


622 


A   TEXT-BOOK  OP   GYNECOLOGY 


all  the  peritoneum,  next  the  omentum,  liver,  stomach,  intestine,  and 
occasionally,  the  pleura.  Where  the  disease  is  unilateral,  the  ovary  on 
the  opposite  side  is  frequently  the  seat  of  metastasis,  and  Steffeck  has 
often  found  it  to  contain  metastatic  deposits,  when  macroscopically  it 


Fig.  269  (Whitacre). — Cystadenoma. — Kothrock  (page  621). 


appeared  normal.  Heinrichs  observes,  also,  that  bilateral  develop- 
ment is  commonly  the  result  of  metastatic  involvement  from  one 
ovary  to  the  other. 

Secondary  carcinoma  of  the  ovary  is  rare,  and  usually  follows  car- 
cinoma of  the  uterus,  especially  of  the  body.  It  has,  however,  been 
observed  to  follow  carcinoma  of  the  stomach  and  mammary  gland,  the- 
result  of  metastasis.  Like  other  epithelial  neoplasms  of  the  ovary,, 
primary  carcinoma  may  have  its  origin  in  the  Graafian  follicle  or  in 
the  germinal  epithelium. 

Sarcoma  of  the  ovary  is  of  much  less  common  occurrence  than  car- 
cinoma. Cohn  estimates  the  frequency  as  compared  with  ovarian. 
cysts  at  1  per  cent,  and  as  constituting  10  per  cent  of  malignant 
tumours  of  the  ovary.  On  the  other  hand,  Pfannenstiel,  in  400  ovari- 
otomies, found  sarcoma  of  the  ovary  in  the  proportion  of  5.38  per 
cent.     With  these,  however,  he  included  endothelioma. 

Primary  sarcoma  of  the  ovary  may  occur  at  any  period  of  life,  in 
childhood  as  well  as  in  advanced  age,  and  Doran  has  observed  it  in- 


NEOPLASMS  OP   THE   OVARIES 


623 


volving  both  ovaries  of  a  seven  months'  foetus.     It  appears  to  be  more 
frequently  met  with,  however,  between  the  ages  of  twenty  and  thirty. 
It  is  frequently  bilateral,  though,  as  Heinrichs   observes,  this  may 
sometimes  be  the  result 
of    metastasis,    only    one 
ovary    having    been   pri- 
marily involved. 

Sarcoma  belongs  to 
the  solid  tumours  of  the 
ovary,  and  is  usually 
rounded  or  cylindrical  in 
shape  with  a  smooth  sur- 
face, though  it  may  be 
irregular  in  contour,  pre- 
senting a  nodular  appear- 
ance. The  size  of  the 
tumour  varies  and  may 
sometimes  reach  a  weight 
of  20  to  30  pounds  or 
more,  if  left  to  run  its 
course  without  surgical 
intervention.  Usually, 
however,  the  presence  of 
the  tumour  is  manifested 
by    symptoms    before    it 

attains  a  great  size.  The  consistence  of  the  tumour  depends  upon  its 
histologic  structure.  If  made  up  largely  of  spindle  cells,  it  will  be 
firm,  resembling  fibroma,  whereas,  if  composed  chiefly  of  rovmd  cells, 
it  will  be  soft,  and  often  of  brainlike  consistence.  Frequently,  these 
tumours  contain  much  fibrous  tissue,  when  they  are  called  fibrosar- 
coma. 

Usually,  the  entire  ovary  is  replaced  by  the  tumour  mass,  though, 
occasionally,  the  remains  of  ovarian  tissue  may  still  be  seen  on  its 
surface.  The  tumour  is  commonly  surrounded  by  an  outer  wall, 
which  is  in  many  instances  so  thin  and  delicate  that  the  fingers  may 
be  thrust  through  it.  These  timiours  are  usually  attached  by  a  short 
pedicle,  and  are  seldom  adherent  to  the  neighbouring  viscera,  but  are 
frequently  accompanied  by  ascites.  On  section,  they  represent  a  yel- 
lowish white,  gray,  or  pink  surface,  the  colour  depending  on  their 
structure  and  blood  supply.  Cyst  formations  are  by  no  means  infre- 
quent, and  are  usually  the  result  of  hemorrhagic  infarcts  or  extrava- 
sations of  blood  into  the  tumour  substance  with  subsequent  soften- 
ing, or  of  fatty  degeneration  of  the  tumour  cells.  Histologically, 
sarcoma  consists  of  a  diffuse  infiltration  of  the  ovarian  stroma  by  sar- 
coma cells,  the  variety  most  commonly  found  being  round  or  spindle 
cells  (Fig.  271).  Frequently  both  round  and  spindle  cells  are  present  in 
the  same  tumour. 


Fig.  270  (  Whitacee). — "  The  microscopic  evidence  of 
malignant  change  consists  in  a  proliferation  of  the 
epithelial  cells  with  atypical  arrangement." — Eoth- 
BOCK  (page  621). 


624 


A  TEXT-BOOK   OF   GYNECOLOGY 


Fig.  271  (Whitacee). — ''Sarcoma  consists 
of  a  ditfuse  infiltration  of  the  ovarian 
stroma  by  sarcoma  cells."  —  Kothrock 
(page  623). 


In  the  order  of  malignancy,  the  small  round-celled  variety  stands  first, 
while  fibrosarcoma  appears  in  many  instances  to  be  relatively  benign. 
Eothrock  has  observed  a  case  of  spindle-celled  sarcoma  involving 
both  ovaries,  in  which  the  patient  died  of  metastasis  to  the  perito- 
neum six  months  after  operation  for  their  removal. 

Metastasis  to  other  organs  of 
the  body  occurs,  acording  to  Te- 
mesvary,  in  the  following  order  of 
frequency:  peritoneum,  omentum, 
stomach,  pleura,  lungs,  uterus,  liv- 
er, diaphragm,  kidney.  Sarcoma  of 
the  ovary  frequently  undergoes  de- 
generative changes,  the  most  com- 
mon of  which,  are  myxomatous  and 
fatty  degenerations. 

Endothelioma  of  the  Ovary. — 
Occupying  an  intermediate  place 
between  carcinoma  and  sarcoma, 
there  is  a  group  of  malignant  tu- 
mours of  the  ovary  possessing 
many  of  the  clinical  features  of 
both,  but  differing  from  them  in 
anatomic  structure. 

Leopold,  first,  in  1874,  de- 
scribed a  case  under  the  name  of  lymphangeioma  cystomatosum.  Tu- 
mours of  similar  structure  had,  previously  to  this,  been  frequently  ob- 
served occurring  in  other  regions  of  the  body,  and  were  called  angio- 
sarcoma and  lymphangeiosarcoma. 

Marchand,  in  1879,  was  the  first  to  give  a  detailed  description  of 
these  tumours  and  to  distinguish  them  from  both  carcinoma  and  sar- 
coma, in  spite  of  the  great  similarity  in  many  respects  to  the  struc- 
ture of  both.  He  named  them  endothelioma,  thus  denoting  their 
origin  from  the  endothelium  of  the  blood  or  lymph  vessels.  Since 
then,  tumours  of  the  same  kind  have  been  described  by  different  au- 
thors, so  that  we  may  now  form  some  conclusions  concerning  the  most 
important  features  of  these  growths. 

Endothelioma  of  the  ovary  is,  in  most  instances,  a  solid  tumour 
(Fig.  272).  It  has  been  met  with  most  frequently  in  middle  age  or 
beyond  it,  though  Leopold  has  observed  it  in  an  eight-year-old  girl,  and 
Olshausen  in  a  girl  seventeen  years  of  age. 

These  tumours  vary  in  size  from  that  of  a  closed  fist  to  that  of  a 
man's  head,  and  are  usually  unilateral,  though  bilateral  tumours  have 
been  observed.  In  shape,  they  are  commonly  rounded,  or  they  may 
be  multinodular  or  lobulated.  The  surface  of  the  tumour  may  be 
smooth  or  rough,  and  its  consistence  firm  or  soft.  Usually  the 
tumour  is  attached  by  a  short  pedicle,  and  it  frequently  forms  adhe- 
sions to  the  surrounding  structures. 


NEOPLASMS  OF   THE  OVARIES 


625 


Fig.  272. — "Endothelioma  of  the  ovary  is  in 
most  instances  a  solid  tumour."  —  Eoth- 
EOCK  (page  624). 


On  section,  the  cut  surface  is  of  a  yellow,  gray,  or  white  colour, 
often  brainlike  in  appearance  and  consistence,  and  easily  torn  by  the 
finger.  Frequently,  it  is  made  up  largely  of  fibrous  structure  in  which 
are  present  nodular  areas  of  softer 
consistence.  Again  the  tumour 
may  be  composed  of  numerous 
small  cysts  in  a  rather  dense 
stroma,  thus  giving  it  a  honey- 
combed or  worm-eaten  appear- 
ance (Pick).  In  other  instances, 
the  tumour  appears  cavernous, 
or  may  be  laminated  in  struc- 
ture. Cyst  formation  occurs 
■chiefly  in  the  lymphatic  variety. 
Earely,  papillary  formations  have 
been  observed  within  the  cyst,  the 
histologic  structure  of  which  is 
fibrous.  These  tumours  have  their 

origin  in  the  endothelium  of  the  blood  and  lymph  vessels,  and,  histo- 
logically, they  present  the  greatest  variety  of  structure  (Fig.  273). 
Pick  has  distinguished  three  types: 

(1)   A  rosarylike  form,  consisting  of  chains  of  cells  arranged  in 
rows,  lying  in  narrow  spaces  or  clefts  in  the  stroma;  their  borders 

run  parallel,  and  they 
frequently  anastomose 
with  each  other  or  send 
off  branches. 

(2)  The  second  con- 
sists of  glandlike  forma- 
tions which,  on  trans- 
verse section,  furnish  a 
picture  often  difficult  to 
distinguish  from  adeno- 
carcinoma, as  the  lumen 
of  these  glandlike  spaces 
is  often  encroached 
upon  by  several  lay- 
ers of  polymorphous 
cells. 

(3)  The  third  form 
consists  of  a  histologic 
formation  resembling 
alveolar  sarcoma,  and 
appears    as    groups    of 

roiirifled  epithelioid  cell  Ijodies  filling  alveolalike  spaces  in  the  rather 
dense  fibrous  stroma.    Not  infrequently,  all  three  types  may  be  found 
in  the  same  tumour. 
41 


Fig.  273  (Whitaoke). — "  Histologically  they  present  the 
greatest  variety  of  structure." — Rotiirock. 


626  ^  TEXT-BOOK  OF   GYNECOLOGY 

Endothelioma  is  frequently  found  in  combination  with  other 
tumours  of  the  ovary.  The  cases  of  Eckhard,  Flaischlen,  and  Po- 
morski,  were  cystic,  and  contained  dermoid  structures,  while  Pfannen- 
stiel  has  observed  a  combination  of  endothelioma  with  true  epithelial 
cystadenoma.  They  are  very  prone  to  undergo  degenerative  changes,, 
the  most  common  being  hyaline  and  myxomatous  degeneration,  while 
colloid  and  fatty  degeneration  have  also  been  observed. 

Clinically,  they  are  malignant.  In  a  case  of  Leopold's,  which  was 
unsuited  to  operation,  the  patient  died  of  cachexia  within  six  months. 

As  regards  recurrence  following  operation,  there  are  only  scanty 
data  available  upon  which  to  base  an  opinion.  Of  7  cases  tabulated  by 
von  Yelits,  only  3  recovered  from  the  operation.  In  2  cases,  metastasis 
was  observed,  while  4  had  pronounced  cachexia.  Billroth  regarded, 
these  tumours  as  in  the  same  order  of  malignancy  as  carcinoma. 


CHAPTEE    XLI 

NEOPLASMS  OF  THE   OVARIES   (Continued) 

Complications— Symptomatology — Diagnosis  —  Treatment  —  Ovariotomy :  History, 
technique,  results — Incomplete  ovariotomy — Ovariotomy  during  pregnancy. 

The  complications  of  ovarian  tumours  are  various  as  there  is  no  rea- 
son why  an  ovarian  tumour  should  not  develop  in  the  presence  of  any 
other  visceral  lesion.  These  growths  occur,  therefore,  coincidently 
with  neoplasms  of  the  uterus,  cysts  of  the  mesentery,  nephrydrosis, 
hypertrophies  of  the  spleen,  enormous  distentions  of  the  gall  bladder, 
cysts  of  the  urachus,  etc.  Among  the  more  important  complications, 
however,  are  (a)  pregnancy,  (b)  torsion  of  the  pedicle,  (c)  ascites, 
(d)  albuminuria,  (e)  adhesions,  (/)  rupture  of  the  tumour. 

Pregnancy  as  a  complication  of  ovarian  tumour  is  not  an  infre- 
quent occurrence  in  practice.  Sir  Spencer  Wells,  after  an  experience  in 
ovariotomy  greater  than  any  which  had  then  fallen  to  the  lot  of  any 
other  man,  observed  that,  "  certainly  the  most  common  mistakes  in 
the  diagnosis  occur  when  the  tumour  is  enlarged  from  some  cause,  and 
pregnancy  is  the  most  common  of  all  causes  of  enlargement  of  the 
uterus.  When  a  patient  has  no  reason  for  deceiving  her  adviser,  doubt 
or  difficulty  will  often  arise;  and  in  cases  of  pregnancy,  real  or  sus- 
pected, the  patient  may  mislead  the  surgeon  intentionally,  or  from 
her  own  hopes  or  fears  biasing  her  judgment."  This  complication  is 
always  a  condition  of  serious  import.  Pregnancy  is  liable  to  give  a 
fresh  impetus  to  the  growth  of  a  tumour,  while  the  tumour,  in  turn, 
may  exercise  a  deleterious  influence  upon  the  gravid  uterus.  Abortion 
is  not  an  infrequent  sequence.  If  the  case  goes  to  term,  rupture  of  a 
thin-walled  cyst  is  liable  to  occur  as  the  result  of  the  muscular  con- 
traction of  the  abdominal  wall.  Inflammation  resulting  in  adhesions 
between  the  cyst  and  either  the  intestines  or  abdominal  wall,  or  both, 
may  be  induced.  Twisting  of  the  pedicle  may  occur  as  the  result  of 
the  changed  position  of  the  cyst  following  the  collapse  of  the  parturient 
uterus.  Gottschalk  (Frauenarzt)  has  reported  a  case  of  infection  of 
the  cyst  by  the  colon  bacillus,  and  Zetter  has  reported  21  cases  of  cyst 
infection  occurring  during  the  puerperium. 

The  mortality,  both  maternal  and  foetal,  is  very  high  in  these  cases 
when  left  to  themselves.  Heiberg  found  that  25  per  cent  of  mothers, 
and  75  per  cent  of  children,  died  in  271  cases  in  which  pregnancy, 
coexisting  with  ovarian  tumour,  was  permitted  to  go  to  term.     Zetter 

627 


628  A  TEXT-BOOK  OP  GYNECOLOGY 

gives  the  maternal  death-rate  at  about  30  per  cent,  while  Litzmann 
places  it  at  43  per  cent. 

Torsion  of  the  pedicle,  as  the  result  of  axial  rotation  of  the  tumour, 
occurs  with  sufficient  frequency,  and  is  a  complication  of  such  gravity, 
as  to  entitle  it  to  consideration  in  this  connection.  Knowsley  Thorn- 
ton found  a  twisted  pedicle  57  times  in  600  cases  of  ovariotomy.  It 
is  a  complication  to  which  Eokitansky  first  called  attention  in  1865. 
He  described  13  cases,  8  of  them  having  been  encountered  in  post- 
mortem examinations  made  in  58  cases  of  ovarian  disease.  Sir  Spencer 
Wells,  Kolb,  Peaslee,  and  Barnes,  were  among  the  early  observers  of 
this  complication. 

The  causes  of  axial  rotation  of  ovarian  tumours  have  been  the  sub- 
ject of  repeated  speculation.  Tait  advanced  the  theory  that  descending 
masses  of  faecal  matter  caused  the  tumour  to  turn.  Doran  believes 
{Tumours  of  the  Ovary)  that  the  twisting  of  a  pedicle  is  to  be  explained 
by  the  simpler  doctrine  that  the  tumour,  pressed  upon  by  the  viscera, 
and  even  by  the  costal  cartilages  above  and  the  pelvic  structures  below, 
but  comparatively  free  laterally  and  anteriorly,  rotates  on  its  own 
axis  every  time  the  patient  after  walking  or  lying  on  her  back  turns 
round  and  rests  on  her  side.  Accidents,  direct  violence,  sudden  strain, 
and  sudden  change  of  position,  were  the  determining  causes  of  the 
attack  in  8  of  Thornton's  cases.  Pregnancy  seems  to  bear  a  causal  rela- 
tion to  the  complication.  The  pathologic  changes  are  dependent  upon 
the  mechanical  obstruction  to  the  efferent  circulation.  The  compara- 
tively firm  and  relatively  noncompressible  arteries  continue  to  pump 
blood  into  the  tumour,  while  the  obstructed  veins  can  not  carry  it  out. 
As  a  result,  there  is  an  enormous  increase  in  the  volume  of  the  growth, 
accompanied  by  acute  pain  which  is  referred  chiefly  to  the  pedicle,  a 
fact  which  Thornton  considers  due  to  the  pressure  to  which  the  nerves 
are  subjected  at  that  point.  In  extreme  cases,  the  pain  extends  over 
the  entire  area  of  the  tumour.  Coincidently  with  this  turgescence  of 
the  tissues,  there  occurs  a  transudation  of  sanguiferous  elements  upon 
the  surface  of  the  tumour.  In  some  cases,  the  blood  vessels  rupture 
either  into  the  peritoneal  cavity  or  into  the  cavity  of  the  tumour. 
Secondary  rupture  of  the  hemorrhagic  tumour,  the  blood  and  pseudo- 
mucinous contents  escaping  into  the  peritoneum,  has  been  noted. 
The  incised  wall  of  a  tumour  the  pedicle  of  which  has  been  twisted, 
reveals  numerous  hemorrhages,  varying  from  punctate  clots  to  large 
hematomata.  While,  as  a  rule,  these  tumours  perish  by  the  necrosis 
induced  by  strangulation,  there  are  exceptional  instances  in  which 
they  have  survived  by  virtue  of  nutrition  derived  from  the  newly 
formed  peripheral  adhesions.  These  are  a  distinct  feature  of  the  patho- 
logic changes  observed  in  the  majority  of  cases.  Eeed  has  had  a  case 
in  which  there  was  a  distinct  history  of  rotation  of  the  tumour,  but 
in  which  operation  was  denied  because  the  patient  was  in  extremis. 
After  several  days  her  symptoms  began  to  improve,  and  six  months  later 
she  was  in  good  health  with  a  tumour  of  diminished  volume. 


NEOPLASMS   OF   THE  OVAEIES  629 

The  symptoms  of  twisted  pedicle  are^,  sudden  pain  in  the  ovarian 
region,  which  may  extend  rapidly  over  the  area  of  the  tumour,  and 
rapid  increase  in  volume  of  the  tumour,  the  patient  manifesting  signs 
of  shock,  associated  sooner  or  later  with  evidences  of  systemic  toxaemia. 
Vomiting  may  or  may  not  be  present.  The  diagnosis  is  not  difficult  if 
an  ovarian  tumour  is  known  to  exist.  There  is  frequent  extensive 
peritoneal  tenderness.  The  treatment  of  this  condition  is  by  immediate 
ovariotomy. 

The  changes  observable  in  a  cyst  with  a  twisted  pedicle  are,  first, 
oedema  of  the  cyst  wall,  and,  next,  distention  of  the  sac.  Serous  exu- 
dation from  the  circulation,  following  in  the  direction  of  least  resist- 
ance, takes  place  as  a  rule  into  the  cyst  cavity  rather  than  upon  its 
surface.  A  certain  amount  of  transudation  is,  however,  observable  on 
the  surface,  a  condition  which  favours  the  speedy  development  of  ad- 
hesions. The  blood  pressure  becomes  so  great  that  hemorrhages  fre- 
quently occur,  as  a  rule  into  the  cavity  of  the  cyst,  but  occasionally 
upon  the  surface.  It  is  rare  that  the  cystic  fluid  in  these  cases  is  not 
discoloured  by  blood  elements.  The  blood  pressure  may  become  so 
great  as  to  induce  cell  necrosis. 

The  treatment  of  twisted  pedicle  is  incontestably  by  operation;  "  the 
only  question  admitting  of  discussion,"  says  Eichardson  {Virginia 
Medical  Semimonthly),  "  is  that  of  the  most  advantageous  time.  The 
conditions  in  one  case  demanding  operation,  in  another  justifying  it, 
are  not  unlike  those  seen  in  appendicitis  and  in  extrauterine  preg- 
nancy. Under  some  circumstances  intervention  should  be  delayed  for 
a  more  favourable  moment;    under  others  it  can  not  be  too  prompt. 

"  It  can  not  be  too  prompt  when  the  lesion  is  recognised  before 
shock  has  become  profound,  and  before  sepsis  has  become  pronounced. 
Nor  can  it  be  too  early  when  the  symptoms  are  increasing,  even  if 
shock  and  sepsis  are  grave  enough  seriously  to  compromise  the  imme- 
diate success  of  intervention.  When,  however,  the  patient  is  improv- 
ing, when  the  immediate  effects  of  hemorrhage,  of  sepsis,  or  of  both, 
are  being  recovered  from,  then  the  wisdom  of  intervention  must  be 
questioned.  The  patient  must  be  carefully  watched  and  a  time  awaited 
when  she  can  safely  withstand  the  added  shock  of  operation.  In  the 
lesion  under  consideration  the  pulse  is  the  most  valuable  guide.  What- 
ever the  other  signs  may  be,  whether  the  temperature  be  high  or  low, 
whether  there  be  tenderness  or  not,  whether  there  be  distention,  rigid- 
ity, vomiting,  obstipation — in  a  word,  whether  there  be  general  peri- 
tonitis or  not,  the  tumour  should  be  removed  immediately  if  the 
pulse  is  good.  More  than  this,  it  must  be  removed  if  it  is  getting  worse. 
On  the  other  hand,  a  pulse  that  from  being  bad  is  rapidly  improving, 
justifies  p  short  delay,  even  if  other  signs  are  bad.  When  all  signs, 
from  being  grave,  are  improving,  a  reasonable  delay  is  but  common 
sense.  To  wait  for  improvement  when  there  is  no  sign  of  improvement 
seems  to  mo  unjustifiable;  for  too  often,  especially  in  hemorrhage, 
there  will  be  no  improvement.    The  risk  of  intervention  must  be  taken. 


630  '       ^  TEXT-BOOK  OF   GYNECOLOGY 

When  bleeding  is  suspected,  and  when  the  pulse  is  poor  or  impercep- 
tible, intravenous  injections  of  salt  solution  should  be  made,  and  the 
utmost  speed  of  enucleation  used.  In  the  profound  shock  of  general 
peritoneal  infection  without  hemorrhage,  salt  solutions  may  also  be 
used,  but  here  one  must  not  be  disappointed  by  failure.  In  hemor- 
rhage, an  infusion  of  salt  solution  into  the  veins  adds  the  circulating 
medium  needed  by  the  flagging  heart;  in  sepsis  it  simply  dilutes  an 
abundant  supply  of  vitiated  blood — in  the  one  case  it  tides  the  patient 
successfully  over  a  grave  crisis;  in  the  other  it  merely  postpones  the 
fatal  event. 

"  Whether  delay  be  practised  or  not,  every  efl^ort  should  be  made  to 
add  to  the  j^atient's  strength.  In  addition  to  intravenous  injections, 
stimulating  enemata  of  hot  salt  solution  and  brandy  and  coffee  should 
be  given.  If  not  vomiting,  the  patient  should  be  given  stimulants  by 
mouth.  Hypodermic  injections  of  strychnine,  brandy,  ether,  and 
other  cardiac  stimulants  may  be  given.  The  whole  body  should  be 
kept  warm  by  means  of  hot-water  bottles  and  hot  blankets,  and  the 
foot  of  the  bed  should  be  elevated.  While  the  strength  is  being  re- 
stored in  this  manner,  preparations  for  operation  should  be  made. 
It  is  important,  especially  if  free  blood  is  in  the  abdominal  cavity,  that 
the  operation  be  extremely  aseptic,  because  infection  is  so  apt  to  take 
place  after  hasty  preparations  of  the  operative  field.  Yet  in  advancing 
shock  and  hemorrhage  it  may  not  be  possible  to  sterilize  thoroughly 
the  field,  lest  the  patient  die  before  the  operation  can  be  begun.  The 
risk  of  infection  from  hasty  and  incomplete  preparation  must  there- 
fore be  taken. 

"  It  must  not  be  inferred,  however,  that  so  hasty  an  intervention 
is  always  demanded.  In  all  but  one  of  the  cases  here  reported  the 
operation  was  performed  after  due  consideration;  the  patient  recovered 
fully  from  the  initial  shock,  and  was  operated  upon  some  time  later. 
In  but  one  was  immediate  operation  performed,  and  in  that  case  there 
was  already  a  fatal  gangrene.  Hemorrhage  was  an  important  factor  in 
but  one  instance." 

Ascites  is  sometimes  caused  by  an  ovarian  tumour  vidth  which  it 
may  then  coexist  as  a  complication.  It  is  to  be  remembered,  however, 
that  in  many  of  these  cases,  the  intraperitoneal  accumulation  of  fluid 
may  be  the  result  of  cardiac,  renal,  oi'  hepatic  disease.  Care  should 
be  exercised  to  ascertain  as  nearly  as  possible  the  exact  condition  of 
these  organs,  and  their  possible  causal  relation  to  the  ascites.  If  any 
of  them  present  diseased  conditions  they  should  be  subjected  to  appro- 
priate treatment.  It  is  true  that  this  treatment  may  sometimes  need 
to  begin  Avith  ovariotomy,  for  renal,  hepatic,  and  intestinal  complica- 
tions may  be  caused  in  the  first  instance,  either  by  direct  pressure  from 
a  large  ovarian  tumour,  or  by  the  mechanical  interference  of  that 
tumour  with  the  portal  circulation.  As  a  rule,  however,  such  condi- 
tions may  be  found  amenable  to  treatment  before  ovariotomy  is  per- 
formed, and  when  this  can  be  accomplished  it  should  be  done.    Douglas 


NEOPLASMS  OP  THE   OVARIES  631 

says  that  a  small  tumour,  with  ascites  appearing  early,  is  strongly  pre- 
sumptive of  malignancy.  If  the  ascites  is  from  obstructed  circulation, 
the  liquid  will  be  a  limpid  fluid  resembling  water,  perhaps  slightly 
coloured,  containing  a  little  albumin  but  no  fibrin,  and  giving  no 
sediment.  If  the  ascites  is  from  peritoneal  inflammation,  the  liquid 
will  be  thinner  but  never  transparent,  always  cloudy,  looking  like  but- 
termilk, and  smelling  like  decayed  cheese.  If  the  effusion  is  from 
simple  serous  irritation,  the  liquid  will  be  albuminous,  rather  clear, 
though  sometimes  coloured  like  bile.  In  the  sediment  will  be  found  ele- 
ments of  great  importance.  Large  irregular  cells  may  be  seen,  having 
a  central  nucleus  surrounded  by  a  quantity  of  granulations.  The 
presence  of  these  cells  is  usually  taken  as  a  sign  of  malignant  growth. 

Albuminuria  is  of  frequent  occurrence  in  connection  with  the 
larger  cysts  of  the  ovary.  When  the  growth  attains  such  a  size  that 
it  exerts  pressure  upon  the  kidneys,  albumin  is  almost  s^ire  to  appear 
in  the  urine,  the  condition  being  practically  analogous  to  that  which 
is  frequently  found  in  pregnancy.  If  the  disease  has  been  of  long 
standing,  the  changes  thereby  induced  in  the  kidney  may  have  reached 
the  destructive  degree.  It  is  highly  important,  as  a  matter  of  routine, 
that  the  urine  be  investigated  in  all  these  cases  before  operation.  The 
facts  thereby  elicited  will  have  an  important  bearing  upon  the  selec- 
tion of  an  anaesthetic  and  upon  the  prognosis  of  the  case. 

Adhesions  are  liable  to  occur  as  the  result  of  mechanical  hypergemia, 
traumatism,  or  infection  of  the  tumour.  Adhesions  may  be  single  or 
multiple,  firm  or  friable,  local  or  general,  and  may  bind  the  tumour 
to  either  the  visceral  or  the  parietal  peritoneum.  Adhesions  between 
the  tumour  and  the  intestines,  the  abdominal  wall,  or  the  omentum, 
^re  naturally  the  more  frequent.  While  it  is  true  that  peritonitis  ordi- 
narily results  in  the  formation  of  adhesions,  yet,  Douglas  and  others 
have  reported  cases  in  which  such  a  result  did  not  follow  distinct  in- 
flammatory attacks.  Persistent,  definitely  localized  pain,  of  the  trac- 
tion variety,  at  some  point  of  the  surface  of  the  tumour  is  suggestive 
of  adhesion,  but  the  condition  can  not  be  said  to  present  a  definite 
■symptomatology. 

Rupture  of  the  tumour,  when  cystic,  may  be  induced  by  overdis- 
tention,  papillomatous  degeneration,  infection,  or  violence.  It  fre- 
quently happens  that,  in  cysts  of  the  pseudomucinous  variety,  the 
secondary  peripheral  growths  have  very  thin  walls,  and  are,  conse- 
quently, more  liable  to  rupture  from  any  of  the  preceding  causes.  The 
larger  sacs,  however,  have  been  known  to  empty  their  entire  contents 
into  the  peritoneal  cavity.  This  is  an  accident  which  may  or  may  not 
produce  profound  symptoms.  If  the  rupture  is  slight,  the  sac  small,  and 
the  fluid  bland,  the  accident  may  be  almost  symptomless;  whereas,  if  the 
rupture  is  extensive,  the  sac  voluminous,  and  the  fluid  irritating  or 
septic,  the  symptoms  may  be  those  of  profound  shock,  followed  by  acute 
peritonitis  and  septicaemia.  There  is  no  means  of  determining  in  ad- 
vance of  exploration  the  exact  character  of  the  fluid  of  any  ovarian 


632  A  TEXT-BOOK  OF  GYNECOLOGY 

tumour.  Pure  pseudomucin  is  not  irritating,  nor  is  it  septic,  but  if 
the  tumour  has  become  the  seat  of  infection,  however  slight,  this  ma- 
terial serves  as  a  convenient  culture  medium,  and  may  thus  become  the 
source  of  contamination.  When  there  are  grounds  for  suspecting  rup- 
ture of  the  sac,  the  indication  is  for  inunediate  operation  by  abdominal 
section. 

The  symptomatology  of  ovarian  neoplasms  is  sometimes  very  ob- 
scure. In  certain  forms  of  ovarian  growth,  notably  in  dermoids,  there 
is  pain  from  a  very  early  period.  In  a  majority  of  cases,  however,  there 
is  nothing  more  than  a  vague  sense  of  discomfort  in  the  pelvis,  due 
to  the  weight  and  tension  exercised  by  the  developing  tumour.  In 
many  cases,  there  are  no  symptoms  whatever  to  attract  attention  to 
the  pelvis  until  the  patient  by  accident  discovers  that  she  has  an  en^ 
largement  in  either  one  or  the  other  lower  quadrant  of  the  abdomen. 
There  may  or  may  not  be  disturbance  of  the  menstruation,  and,  even 
in  ovarian  tumours  of  large  development,  the  menstrual  function  seems 
to  be  but  slightly  modified.  This  modification  of  function  may  tend 
in  the  direction  of  either  increase  or  diminution  of  the  flow.  In  those 
cases  in  which  the  flow  has  increased,  there  will  generally  be  found 
an  antecedent  history  of  pelvic  disturbance — probably  of  an  endo- 
metritis. In  cases  of  amenorrhoea  due  to  developing  ovarian  cystoma,, 
the  disappearance  of  menstruation,  coincidently  with  abdominal  dis- 
tention, may  lead  to  a  suspicion  of  pregnanc3^  Cases  of  this  kind  are 
of  frequent  occurrence.  While  the  tumour  is  yet  relatively  small,  it 
occupies  a  position  within  the  true  pelvis,  but  as  it  grows  larger  it 
ascends  into  the  abdominal  cavity  just  as  does  a  pregnant  uterus. 
When  the  tumour  is  yet  within  the  pelvis,  its  weight  generally  causes. 
it  to  fall  into  the  cul-de-sac  of  Douglas,  usually  either  to  one  side 
or  the  other  of  the  uterus.  At  this  stage  of  its  develo23ment,  bimanual 
examination  will  enable  the  surgeon  to  outline  the  growth,  and  per- 
haps to  determine  from  which  side  it  develops.  It  is  generally  felt 
as  a  hard,  or  semi-fluctuating  globular  mass,  its  spherical  outline  being 
readily  detected  by  palpation  through  the  abdominal  wall.  To  deter- 
mine the  side  from  which  it  develops  and  the  location  of  its  pedicle, 
Hegar  advises  drawing  down  the  uterus  with  a  tenaculum,  employing 
the  rectal  touch  or  bimanual  manipulation  to  outline  the  attachment. 
The  mobility  of  the  tumour  depends  upon  the  length  and  size  of  its 
pedicle,  which  is  sometimes  long  enough  to  permit  the  growth  to  be 
carried  far  up  to  the  pelvic  brim,  while  in  other  cases  it  is  so  short 
that  the  tumour  feels  more  like  an  abscess  than  a  neoplasm.  In  some 
eases,  the  tumours  are  bilateral,  a  circumstance  which  may  readily  be 
confused  with  a  multiloeular  or  a  multinodular  growth.  The  uterus 
is  very  liable  to  be  displaced  to  either  one  side  or  the  other — or,  as 
occasionally  happens,  the  growth  may  be  poised  above  and  behind  the 
womb,  forcing  the  latter  forward  into  a  state  of  extreme  ante  version. 
As  the  tumour  grows  larger,  however,  and  descends  into  the  abdominal 
cavity,   its   spherical   outline   becomes   more   and   more   apparent   by 


NEOPLASMS   OP   THE   OVARIES  (533 

abdominal  palpation.  Irregular  bosses  or  protuberances  upon  the 
surface  of  the  growth  indicate  that  it  is  multilocular.  On  percussion, 
the  tumour  will  yield  dulness  over  its  entire  area.  One  of  the  essential 
diagnostic  signs  relied  upon  by  Dunlap,  who  was  one  of  the  very  earliest 
of  the  world's  ovariotomists,  was  the  position  of  the  intestines.  As  the 
tumour  develops  from  one  side  or  the  other  of  the  pelvis,  the  bowels 
are  pushed  upward  and  toward  the  opposite  side.  Abdominal  reso- 
nance is  restricted  to  the  area  occupied  by  the  intestines.  This  position 
should  be  more  or  less  constant.  If  a  patient  with  fluctuating  disten- 
tion of  the  abdomen  yields  an  area  of  dulness  in  the  lower  two  quad- 
rants of  the  abdomen,  with  a  resonant  note  above,  and  if  she  mani- 
fests these  signs  both  when  sitting  and  lying,  it  may  be  safely  assumed 
that  she  is  either  pregnant  or  is  the  victim  of  an  ovarian  tumour.  If, 
however,  upon  lying  down,  the  area  of  resonance  descends  toward 
the  pubes,  a  suspicion  of  ascites,  rather  than  of  either  of  the  fore- 
going, is  justifiable.  As  the  cyst  increases  in  size  and  weight,  it  exer- 
cises increasing  pressure  upon  the  neighbouring  viscera;  this  is  the 
frequent  cause  of  vesical  irritation,  constipation,  and  occasional  pro- 
found disturbance  of  the  kidneys.  The  urine,  under  such  circum- 
stances, becomes  scanty,  is  loaded  with  albumin,  and,  if  the  pressure 
is  long  sustained,  oedema  of  the  extremity  is  the  result.  Hemorrhoids 
are  another  annoying  result  of  pressure.  Areas  of  pelvic  tenderness 
are  sometimes  complained  of  when  the  tumour  has  attained  consider- 
able size.  These  are  generally  the  results  of  either  pressure  or  slight 
traumatisms,  and  depend  upon  the  fact  that  the  tumour,  after  attaining 
considerable  size,  may  lose  areas  of  protective  epithelium  and  form 
adhesions  to  either  the  visceral  or  the  parietal  peritoneum. 

The  diagnosis  of  ovarian  neoplasms  is  of  importance,  not  only  to 
establish  their  existence  and  whether  they  are  ovarian  in  origin, 
but  also  to  determine  whether  or  not  they  are  malignant.  The  effort 
to  distinguish  with  accuracy  between  the  different  varieties  of  benign 
neoplasms  is  to  be  looked  upon,  from  the  practical  standpoint,  largely 
as  a  useless  expenditure  of  energy  and  a  waste  of  valviable  time.  It 
may  be  stated  as  a  rule  to  which  there  are  no  exceptions,  that  ovarian 
growths,  either  by  virtue  of  their  primary  characteristics,  or  in  con- 
sequence of  secondary  changes,  tend  to  the  death  of  the  patient. 
It  follows  from  this  fact  that  all  ovarian  growths  should  be  sub- 
jected sooner  or  later  to  extirpation.  The  tendency  to  malignant 
degeneration,  already  noted,  renders  it  important  that  even  the  so- 
called  benign  growths  should  be  removed  without  unnecessary  de- 
lay. This  being  true,  it  is  not  necessary  to  subject  the  patient  to 
punchings,  pommelings,  and  punctures,  to  establish  the  exact  vari- 
ety of  the  growth;  for,  after  it  has  all  been  done,  and  the  guessing 
is  all  over,  precisely  the  same  thing  remains  to  be  done.  It  is,  how- 
ever, frequently  important  for  various  reasons  personal  to  the  patient 
to  indulge  in  delay;  and  it  is,  therefore,  important  to  know  with 
approximate    accuracy,    whether    a    given    tumour    is    malignant    or 


^34  '        A  TEXT-BOOK  OF   GYNECOLOGY 

benign.  This  fact,  unfortunately,  is  not  one  that  can  be  easily  deter- 
mined. It  may  be  accepted  as  a  rule,  however,  that  the  more  rapid  the 
growth,  the  more  liable  is  it  to  be  of  a  malignant  character.  The 
solid  tumours  are  of  the  slowest  growth,  while  jDroliferating  cysts  grow 
with  more  rapidity  than  any  other  of  the  benign  neoplasms.  When  a 
grow^th  which  has  been  increasing  at  a  certain  rate  manifests  sudden 
acceleration  in  development,  it  should  become  an  object  of  suspicion; 
the  sudden  increase  may  depend  upon  a  change  of  type  from  benign 
to  malignant,  or,  it  may  mean  that  the  efferent  circulation  of  the 
tumour  has  been  interfered  with,  either  by  pressure  of  the  growth 
itself,  by  torsion  of  the  pedicle,  or  by  other  causes.  The  increase  in 
the  volume  of  a  tumour  due  to  sudden  twisting  of  the  pedicle  is  very 
sudden,  and  is  associated  with  pain,  followed  in  the  course  of  a  few 
days  by  toxEemic  symptoms  due  to  the  absorption  of  necrotic  products 
from  the  tumour  itself.  Increase  of  size  due  to  a  twisted  pedicle  may 
become  spontaneously  arrested,  the  tumour  itself  surviving  by  virtue  of 
nutrition  derived  from  extensive  j)eripheral  adhesions. 

The  diagnosis  of  small  ovarian  tumours  is  relatively  difficult, 
although  Davenport  {Boston  Medical  and  Surgical  Journal)  insists  that 
they  are  usually  accompanied  by  well-marked  symptoms.  He  states, 
however,  that  pain,  while  usually  present,  does  not  bear  any  constant 
relation  in  its  location,  to  either  the  situation  or  the  variety  of  the 
tumour.  Menstrual  disturbances  are  the  rule,  the  variation  tending  in 
the  direction  of  excessive  rather  than  of  diminished  flow.  There  seems 
to  be  a  direct  causal  connection  between  severe  uterine  hemorrhages  and 
cystic  ovaries  when  the  latter  are  closely  adherent  to  the  uterus. 
Uterine  hemorrhage,  associated  with  a  pelvic  tumour  which  is  unin- 
fluenced by  intrauterine  treatment,  is  more  likely  to  be  due  to  an 
ovarian  tumour  than  to  a  fibroid.  Eeflex  symptoms  are  comparatively 
rare,  and,  according  to  Davenport,  occur  chiefly  in  the  later  stages  of 
the  disease. 

The  diagnosis  of  even  large  cystomata  of  the  ovary  is  not  always 
easy.  A  number  of  the  most  distinguished  operators  have  mistaken 
pregnancy  for  an  ovarian  cyst.  It  may  be  stated  that  there  are  but  few 
distinguished  operators  in  the  world  who  have  not  at  one  time  or 
another  made  an  exploratory  incision,  with  the  result  of  finding  a 
pregnant  uterus  instead  of  the  suspected  cyst.  (See  Pregnancy  as  a 
Complication  of  Ovarian  Tumours.)  In  extenuation  of  this  accident, 
it  should  be  remembered  that  an  ovarian  tumour  may  occupy  such  a 
position  as  to  interfere  with  the  detection  of  pregnancy  by  either 
vaginal  or  bimanual  manipulation,  and  it  must  be  remembered,  further- 
more, that  among  the  occasional  erratic  symptoms  of  ovarian  cystoma, 
are  reflex  vomiting  and  mammary  development,  with  enlargement, 
softening,  and  blue  coloration,  of  the  cervix.  In  view  of  these  facts, 
occasional  mistakes  are  to  be  expected.  In  the  great  majority  of  in- 
stances of  pregnancy,  however,  the  placental  bruit  may  be  heard,  while, 
later,  ballottement  may  be  practised;  and,  after  the  period  of  quicken- 


NEOPLASMS   OF  THE   OVARIES  635 

ing,  the  foetal  heart  may  generally  be  detected.  It  must  be  remembered, 
however,  that  even  these  signs  may  be  obscured.  This  is  particularly 
true  of  the  placental  bruit,  which  may  be  completely  masked  by  the 
more  pronounced  bruit  of  the  almost  cavernous  veins  that  develop  in 
certain  of  these  tumours.  Ballottement  may  be  defeated  by  the  ascent 
of  the  uterus  and  the  relatively  low  position  of  the  tumour;  while  the 
foetal  heart  may  be  situated  so  remotely  that  its  pulsations  can  not  be 
heard.  Ascites  is  not  infrequently  mistaken  for  a  unilocular  ovarian 
cyst.  This  is  jiarticularly  true  in  cases  of  encysted  ascites,  where  the 
induced  area  of  dulness  remains  inconstant,  even  when  the  patient 
assumes  different  positions.  The  ascites  of  tuberculous  peritonitis 
frequently  occurs  in  connection  with  tuberculous  involvement  of  the 
mesenteries,  or,  at  least,  of  the  meso-enteron.  The  result  of  tuber- 
culous infection  in  this  locality  is  a  contraction  of  the  peritoneal  fold, 
which  prevents  the  intestines,  even  when  laden  with  gas,  from  floating 
upon  the  surface  of  the  ascitic  fluid.  In  these  cases,  however,  the 
morphology  of  the  growth  may  be  taken  as  a  reasonably  safe  index  of 
its  character.  A  tumour  fluctuating  and  spherical  in  the  upright  pos- 
ture will  maintain  its  outlines  with  but  trifling  variation  when  the 
patient  lies  down,  whereas,  if  the  distention  depends  upon  free  fluid  in 
the  peritoneal  cavity,  the  abdomen  will  flatten  to  a  certain  degree,  while 
there  will  be  a  corresponding  distention  of  the  ilio-costal  interval.  It 
rarely  hapjoens  that  a  tumour  so  develops  as  to  distend  the  abdominal 
wall  between  the  crest  of  the  ilium  and  the  ribs. 

Large  cysts  of  the  mesentery  and  nephrydrosis  have  been  mistaken  for 
ovarian  cysts.  To  distinguish  between  an  ovarian  cyst  and  nephrydrosis 
it  is  important  to  remember  that,  in  the  former,  the  tumour  develops 
from  below  upward,  and  in  the  latter  from  above  downward.  In  the 
former,  the  upper,  and  in  the  latter,  the  lower  margin  of  the  growth 
is  free.  This  sign  is,  of  course,  absent  when  the  cyst  is  large  enough 
to  fill  the  abdominal  cavity.  If  the  tumour  is  of  congenital  origin,  the 
jDresumption  of  nephrydrosis  is  strengthened,  although  Alban  Doran 
has  reported  a  case  of  congenital  ovarian  tumour.  The  position  of 
the  colon  relatively  to  the  cysts  is  important  in  distinguishing  between 
these  two  conditions.  In  many  cases,  the  bowel  can  not  be  palpated  or 
percussed;  under  which  circumstances  Simon  introduced  an  effervescing 
enema  to  distend  the  bowel.  Exploratory  puncture  has  been  practised 
as  a  diagnostic  means  in  cases  of  suspected  nephrydrosis,  but  it  is  not  to 
be  recommended,  not  only  for  the  reasons  already  enumerated,  but 
because,  according  to  Pozzi,  the  fluid  from  nephrydrosis  is  no  more 
characteristic  than  is  that  from  the  proliferating  serous  cyst  of  the 
ovary  or  of  the  parovarium.  Urea  and  uric  acid  may  be  absent  from 
nephrydrosis  and  present  in  an  ovarian  cyst,  a  circumstance  which  will 
only  tend  to  increase  the  pre-existing  confusion.  Urethral  catheteriza- 
tion, as  practised  by  Pawlick  and  Kelly,  may  be  of  value  in  distinguish- 
ing between  these  two  frequently  confusing  conditions. 

E (^hinococcous  cysts  of  the  peritoneal  cavity  may  be  mistaken  for 


636  '        A  TEXT-BOOK  OF   GYNECOLOGY 

ovarian  tumours.  They  acquire  great  volume  and  give  rise  to  corre- 
sponding distention  of  the  abdominal  walls.  The}-  may  displace  vis- 
cera, encroach  upon  the  diaphragm,  and  occasion  interference  with 
the  action  of  the  heart  and  lungs,  just  as  occurs  in  cases  of  advanced 
or  neglected  ovarian  tumours.  The  facts,  however,  that  the  growth 
started  in  one  of  the  upper  quadrants  of  the  abdomen,  generally  the 
right,  extending  thence  toward  the  pelvis,  and  that  the  growth  is  more 
rapid  than  is  ordinarily  the  case  in  pelvic  tumours,  Avill  place  the 
practitioner  upon  his  guard.  The  fluctuation  in  hydatids  is  remote 
and  circumscribed.  The  hydatid  fremitus  is  considered  characteristic 
and  decisive.  It  is  presumed  that,  in  the  majority  of  these  cases, 
the  origin  of  the  parasitic  infection  is  in  the  liver,  and  that  the  con- 
tamination of  the  peritoneum  is  consecutive  to  rupture  of  a  lymphatic 
cyst  and  the  consequent  escape  of  the  echinococci  into  the  peritoneal 
cavity.  When  once  implanted  in  the  peritoneum,  however,  these  para- 
sites may  go  on  multiplying  in  any  one  cavity.  They  may  vmdergo 
retrogressive  changes  and  may,  themselves,  become  the  seat  of  bacterial 
infection.  Sir  Spencer  Wells  has  recorded  a  case  in  which  the  degenera- 
tion of  the  hydatid  cysts  was  associated  Avith  the  formation  of  gas,  due^ 
in  all  iDrobability,  to  the  action  of  the  Bacillus  aerogenes  capsulatus. 

Large  malignant  neoplasms  of  the  lynipJiatics  may  occasion  confu- 
sion in  making  a  diagnosis  of  a  seeming  ovarian  tumour.  These 
growths  may  originate  from  the  lymphatic  glands  within  the  broad 
ligament,  or  beneath  the  pelvic  peritoneum,  or  even  higher  up.  Dr. 
Mary  Almira  Smith,  of  Boston,  has  reported  an  interesting  case  in 
which  a  large  malignant  growth  had  developed  from  a  lumbar  lym- 
phatic gland.  It  was  the  size  of  a  child's  head  and  presented  all  the 
physical  characteristics  of  an  ovarian  tumour. 

Phantom  tumour  yields  a  resonant  note  on  percussion  and  entirely 
disappears  under  anaesthesia. 

A  distended  Madder  has  been  mistaken  by  very  capable  physicians 
for  an  ovarian  cyst.  When  the  fluctuating  tumour  occupies  a  median 
position  and  extends  to  the  symphysis  pubis,  and  when  it  can  not  be 
moved  from  this  position,  a  catheter  should  always  be  inserted  as  a 
precautionary  measure.  The  indication  for  catheterization  is  positive 
when  the  patient  complains  of  slight  incontinence. 

Fiirocystoma  of  the  uterus  may  present  many  physical  signs  in  com- 
mon with  an  ovarian  tumour.  Eishmiller,  in  this  connection,  calls 
attention  to  the  fact  that  fibrocystoma  of  the  uterus  is  relatively 
infrequent  and  occurs  usually  in  women  over  thirty  years  of  age.' 
Its  growth  is  slow  at  first,  but  rapid  after  attaining  a  certain  size. 
Menorrhagia  is  seldom  present.  In  fibrocystoma  we  have  a  lobulated 
condition  which  can  be  felt  through  the  abdominal  parietes,  umbilicus 
not  prominent,  uterus  moving  with  the  tumour  and  the  uterine  cavity 
generally  elongated;  while,  in  ovarian  cyst,  we  have  no  lobulation 
except  in  poly  cysts,  the  umbilicus  is  prominent,  the  uterus  moves 
independently  of  the  tumour  and  its  cavity  is  not  elongated.    The  de- 


NEOPLASMS   OF   THE   OVARIES  037 

tection  of  hard  nodules  would  be  significant,  but  hard  and  tense  cysts 
may  impart  the  same  sensation.  Fluctuation  is  very  hard  to  detect 
for  the  reason  that  the  tumour  gives  rather  an  elastic  feel. 

These  confusing  conditions  occurring  with  relative  frequency  in 
the  hands  of  the  most  distinguished  and  experienced  operators,  be- 
came so  apparent  to  Lawson  Tait  that  he  proclaimed,  not  only  the 
expediency,  but  the  importance  of  exploratory  incision  as  a  diagnostitial 
measure.  This  decree  has  been  ratified  by  the  universal  acquiescence 
of  the  medical  profession.  The  presence  of  an  abdominal  tumour  of 
"undetermined  character  and  showing  a  constant  tendency  to  increase 
in  size,  is  of  itself,  not  only  a  justification,  but  an  imperative  indica- 
tion for  an  exploratory  abdominal  section.  The  time  has  long  since 
passed  when  surgeons  felt  justified  in  pronouncing  an  unequivocal 
diagnosis  of  the  exact  character  of  intra-abdominal  growth  upon 
evidence  furnished  by  external  examination  alone. 

Puncture  of  the  cyst  through  the  abdominal  wall,  or  through  the 
vagina,  is  never  a  justifiable  diagnostitial  measure.  The  fact  that 
puncture  is  sometimes  practised  without  incident,  does  not  in  the 
least  demonstrate  that  the  operation  is  without  danger,  or  that  the 
operator  is  without  responsibility.  The  possibility  of  wounding  im- 
portant blood  vessels,  the  location  and  development  of  which  under 
these  circumstances  is  always  anomalous ;  the  possibility  of  punctur- 
ing a  loop  of  intestine ;  the  probabilit}^  of  inducing  a  possibly  septic 
seepage  into  the  peritoneum;  and  the  certainty  of  inducing  adhe- 
sions, are  all  cogent  reasons  against  a  manoeuvre  which,  under  the 
most  favourable  circumstances,  can  only  be  looked  upon  as  groping  in 
the  dark.  The  demonstrated  utility  and  innoeuousness  of  explora- 
tory incision,  u^ndertaken  with  reference  to  the  completion  of  the 
operation  should  it  be  found  justifiable,  renders  preliminary  puncture 
of  the  cyst  neither  necessary  nor  defensible.  It  is  a  matter  of  scientific 
interest,  however,  to  know  that  a  clear  and  noncoagulable  fluid  from 
an  abdominal  cyst  probably  indicates  the  parovarian  origin  of  the 
latter,  although  proliferating  serous  cysts  of  true  ovarian  origin  may 
yield  a  fluid  of  similar  reaction;  whereas,  the  demonstrated  presence 
of  pseudomucin  (see  Test  for  Pseudomucin)  indicates  that  the  cyst 
is  of  true  ovarian  origin. 

If  it  were  true,  which  it  is  not,  that  the  fluid  obtained  by  tapping- 
would  enable  the  surgeon  always  to  recognise  the  exact  character  of 
the  cyst  the  manoeuvre  would  still  be  without  practical  value,  because 
precisely  the  same  treatment,  namely  ovariotomy,  would  be  indicated, 
whether  the  fluid  yielded  pseudomucin  or  not. 

The  treatment  of  neoplasms  of  the  ovaries  is  necessarily  surgical. 
All  attempts  to  cure  these  growths  or  to  arrest  their  progress  and 
development  by  medicines,  manipulations,  or  electricity,  have  proved, 
not  only  futile,  but  in  many  instances  directly  damaging  to  the  pa- 
tient. It  should  be  accoptod  as  a  rule,  that  all  cases  of  ovarian 
tumours   should  be  operated  upon  as   soon  after  the   diagnosis   has 


638  "         ^   TEXT-BOOK  OF   GYNECOLOGY 

been  made  as  the  conditions  will  judiciously  permit.  Delay  may  be 
indulged  in  temporarilj^,  to  improve  the  general  condition  of  the 
patient  and  to  place  her  in  a  better  condition  for  operation.  But  it 
should  never  be  prol  nged  beyond  the  time  necessary  to  put  her  in  the 
best  condition  for  ovariotomy. 

Ovariotomy. — History. — Ovariotomy  was  first  performed  by  Dr. 
Ephraim  McDowell,  who  lived  in  the  town  of  Danville,  in  what  was 
then  known  as  the  backwoods  of  Kentucky.  He  had  been  a  student 
in  Edinburgh  of  John  Bell,  who  had  suggested  in  his  lectures  both 
the  possibility  and  the  advisability  of  removing  ovarian  tumours, 
though  he  himself  had  never  operated  for  this  purpose. 

The  seed  sown  in  the  mind  of  j^oung  McDowell  brought  forth  its 
first  fruit  in  1809,  when  he  removed  a  large  ovarian  tumour  from  Mrs. 
Marion  Crawford,  who  not  only  recovered  from  the  operation,  but 
lived  thirty-eight  years  afterward.  Although  McDowell  did  not  pub- 
lish the  report  of  this  case  and  of  two  other  similar  operations  until 
1816,  his  claim  to  be  the  first  ovariotomist  in  the  world  is  now  every- 
where admitted  without  dispute.  McDowell  performed,  altogether, 
13  ovariotomies,  with  6  deaths. 

The  principal  operators  in  America  to  follow  in  the  footsteps  of 
McDowell  within  the  next  twenty-five  years,  were  Dunlap,  of  Ohio, 
Nathan  Smith,  of  Connecticut,  Peaslee,  of  New  York,  and  the  Atlees 
of  Pennsylvania.  Lizars  operated  in  Edinburgh  in  1824  and  1825, 
but  with  such  poor  success  that  the  operation  did  not  gain  much 
headway  in  Great  Britain  until  1812,  when  Charles  Clay,  of  Man- 
chester, scored  a  success  greater  than  any  operator  up  to  that  date. 
Baker  Brown,  between  1852  and  1856,  performed  9  ovariotomies  with 
7  deaths.  He  operated  no  more  for  four  years,  when  he  began  a  most 
successful  career  which  was  suddenly  cut  off  by  his  untimely  death. 
In  1858,  Spencer  Wells,  of  London,  commenced  his  remarkable  record, 
which,  at  the  time  of  his  death,  had  gone  well  up  toward  2,000  cases. 
He  reduced  the  mortality  of  this  operation  to  25  per  cent  but  never 
got  much  below  that  figure.  In  1862  Thomas  Keith,  of  Edinburgh, 
performed  his  first  operation  and  soon  became  the  most  successful 
living  ovariotomist.  Lawson  Tait,  of  Birmingham,  in  the  course  of  his 
extraordinary  and  startling  career  reported  a  series  of  139  ovariot- 
omies without  a  death.  Bantock  and  Thornton,  of  London,  following 
in  the  footsteps  of  Spencer  Wells,  in  the  Samaritan  Free  Hospital 
of  that  city,  greatly  improved  upon  the  teachings  of  their  master, 
and  reported  long  series  of  ovariotomies  with  much  smaller  mor- 
tality than  Wells  had  ever  been  able  to  secure.  In  France  the  opera- 
tion did  not  make  equally  rapid  headway  until  Pean  and  his  followers 
began  to  do  very  successful  work.  On  the  Continent,  Koeberle, 
Schroder,  Billroth,  Martin,  Leopold,  Sanger,  and  many  others,  began 
and  carried  on  the  good  work,  until  now,  in  all  parts  of  the  world, 
ovariotomy  is  one  of  the  most  successful  of  modern  surgical  opera- 
tions.    Thousands  of  women  have  had  their  lives  saved,  and  have  lived 


NEOPLASMS   OF   THE   OVARIES 


63^ 


long  years  of  usefulness  and  happiness  as  a  final  result  of  McDowell's 
glorious  effort  in  1809. 

Indications. — Ovarian  tumours  should  be  removed  as  soon  as  prep- 
aration can  be  conveniently  made  after  tneir  diagnosis.  There  is  no 
wisdom  whatever  in  delay.  Nothing  can  be  gained  and  everything 
may  be  lost  by  putting  off  the  operation.  No  medicine,  or  outward 
application  or  treatment  of  any  kind  whatsoever,  is  likely  to  cure  an 
ovarian  tumour.  As  ovariotomy  is  the  only  source  of  relief,  the 
sooner  it  is  resorted  to  the  better.  The  life  of  a  woman  with  an  ova- 
rian tumour,  as  a  rule,  is  not  greater  than  three  years  from  the  time 
of  its  discovery.  She  is  likely  never  to  be  in  a  better  condition  for 
the  operation  than  at  the  time  of  diagnosis.  The  chief  indication, 
then  for  ovariotomy  is  a  clear  and  unmistakable  diagnosis. 

Technique. — While  a  full  description  of  the  technique  of  ovarioto- 
my would  require  a  statement  in  regard  to  the  preparation  of  the 
patient,  of  the  operating  room,  of  the  surgeon,  his  assistants  and 
nurses,  the  instruments,  sponges  and  dressings,  etc.,  the  limited  space 
allotted  to  this  chapter  will  not  permit  of  these  otherwise  necessary 
details,  especially  as  the  general  subject  of  operative  technique  is  fully 
described  in  another  part  of  this  work.  Readers  are  referred,  there- 
fore, to  the  chapter  on  general  technique  for  a  descrip- 
tion of  the  arrangement  of  the  sterilized  instruments 
and  towels,  and  of  the  nurses  with  their  sponges  and 
their  basins  of  hot  and  cold  water,  their  sterilized  solu- 
tions, etc.,  while  we  proceed  at  once  with  a  description 
of  the  technique  of  the  "  operation  itself,"  which,  for 
the  sake  of  convenience  and  brevity,  may  be  described 
under  the  following  heads: 

1.  Instruments  required. 

2.  The  angesthetic  and  the  ansesthetizer. 

3.  The  incision  of  the  abdominal  wall. 

4.  Tapping  and  removing  the  contents  of  the  cyst. 

5.  The  treatment  of  adhesions  and  the  ligation  of  the 
pedicle. 

6.  The  toilet  of  the  peritoneum. 

7.  Irrigation  and  drainage. 

8.  Accidents  and  complications. 

9.  Closure  of  the  wound. 

10.  Dressings. 

11.  After-treatment. 

Instruments. — The  instruments  necessary  for  an  un- 
complicated ovariotomy  might  readily  be  carried  in  the 
surgeon's  overcoat  pocket,  but  as  we  so  often  come  upon 
the  unexpected  in  the  abdominal  cavity,  an  experienced 
ovariotornist  will  have  sterilized  at  the  same  time  everything  which 
he  might  require  in  case  he  should  meet  with  complications  and  con- 
ditions which  he  had  not  suspected  when  he  made  his  diagnosis. 


Fig.  274.— Dis- 
secting forceps- 
(page  640). 


640 


A  TEXT-BOOK  OP  GYNECOLOaY 


The  instruments  most  frequently  required  are:  one  or  two  sharp 
scalpels;  a  dozen  hemostatic  forceps;  half  a  dozen  prepared  sponges  or 
gauze  pads;  three  pairs  of  scissors,  one  long  and  straight,  one  curved 
on  the  flat  and  blunt  pointed,  and  one  short,  thick,  strong,  and  curved 


Fig.  275. — Curved  trocar, 


at  right  angles;  two  dissecting  forceps  (Fig.  374)  for  picking  up  the 
peritoneum;  Tait's  or  Spencer  Wells's  trocar  with  long  rubber  tubing 
attached,  to  conduct  the  fluid  into  a  bucket  under  the  table  (Fig.  275); 
two  large  cyst  forceps,  to  grasp  and  withdraw  the  empty  sac;  two  long 
aneurism  needles,  threaded  at  the  point,  for 
transfixing  and  ligating  the  pedicle;  a  good, 
free-working  irrigation  apparatus;  needles  long, 
straight,  and  curved,  to  close  the  abdominal  in- 
cision; an  assortment  of  sterilized  silk,  silkworm 
gut,  and  catgut;  long  perforated  glass  tubes  and 
sterilized  gauze,  to  be  used,  if  necessary,  in 
drainage. 

The  following,  also,  may  be  needed:  An  as- 
sortment of  large  and  small  pressure  forceps 
(Fig.  276),  a  catheter,  retractors,  rubber  cord  or 
tubing,  fine  curved  and  straight  needles,  a  port- 
able electric  light,  an  electro-cautery,  and  Mon- 
sel's  solution.  All  these  instruments,  sutures, 
etc.,  should  be  carefully  assorted  and  placed  in 
approj^riate  trays  upon  a  table  near  by,  and  cov- 
ered with  sterilized  hot  water  by  the  assistant 
who  is  to  hand  them  to  the  operator  as  needed, 
during  the  various  stages  of  the  operation.  A 
basin  of  hot  water  should  be  placed  upon  a  small 
table  near  the  surgeon  in  which  he  can  immedi- 
ately cleanse  his  hands  should  they  become  soiled 
with  pus  or  fluid  from  the  tumour.  This  water 
will  need  to  be  frequently  changed  as  the  opera- 
tion proceeds. 

T^Hiile  these  and  all  other  ^^reparations  by  the 
surgeon  are  going  on,  his  assistants,  and  nurses,  to  insure  an  aseptic 
environment  and  operation,  the  patient,  who  has  also  been  properly 
prepared,  may  be  anaesthetized  in  an  adjoining  room,  thus  preventing 
the  fright  and  shock  of  being  brought  into  the  ojDerating  room  and 


Fig.  276. — Pressure 
forceps. 


NEOPLASMS  OF  THE   OVARIES  641 

placed  upon  the  table  in  plain  sight  of  the  instruments,  the  operator, 
and  his  assistants,  in  their  operating  costumes. 

The  Ancesthetic  and  the  Ancesthetizer. — (See  Anaesthesia.) 

The  Abdominal  Incision. — Although  specially  described  elsewhere 
in  this  work,  it  may  be  well  to  say  here  that  it  need  not  be  longer 
than  3  inches  at  first,  and  should  be  carefully  and  deliberately  made. 
Ueckless  oiDening  of  the  abdominal  cavity  with  one  stroke  of  the  knife 
is  as  unwise  as  it  is  dangerous.  Large  unilocular  ovarian  tumours 
have  been  frequently  removed  by  Joseph  Taber  Johnson  and  others 
through  a  3-inch  incision.  Should  occasion  require,  the  opening  can 
be  easily  enlarged  with  the  scissors,  when  necessary,  to  deal  with 
adhesions  or  to  deliver  partly  solid  tumours  without  bruising  the 
tissues. 

While  advocating  the  short  incision,  one  as  long  as  is  necessary 
is  always  made  as  we  proceed.  It  is  not  needful  to  spend  valuable 
time  in  searching  for  the  linea  alba.  Many  surgeons  think  that  a 
stronger  cicatrix  is  secured  by  the  union  of  the  cut  muscles. 

Before  opening  the  peritoneum,  all  bleeding  should  be  arrested. 
That  membrane  may  now  be  caught  up  between  two  forceps  and 
nicked  with  a  knife  or  scissors.  In  order  to  avoid  the  possibility 
of  injuring  the  intestines,  it  is  safer  to  roll  the  peritoneum  between 
the  thumb  and  finger  before  opening  it.  The  intestines,  if  not 
adherent,  will  immediately  drop  back  out  of  harm's  way  as  soon  as 
air  rushes  in  through  the  opening.  The  incision  is  now  enlarged  with 
the  scissors  upon  the  index  finger,  which  acts  at  the  same  time  as  a 
guide  and  a  protection  to  the  intestines  against  injury  (Fig.  35,  p.  108). 
All  bleeding  having  been  arrested,  two  fingers  of  the  left  hand  should 
be  passed  over  the  face  of  the  tumour  in  all  directions  to  ascertain  the 
nature  and  extent  of  adhesions. 

The  Emptying  of  the  Cyst. — The  pearly-gray  cyst  wall  can  be  readily 
seen  through  the  gaping  edges  of  the  wound,  and  a  large-sized  Tait  or 
Wells  trocar  can  be  passed  into  the  tumour  at  the  upper  angle  of  the 
wound  and  the  fluid  drawn  off  through  a  tube  at  the  end  of  the  trocar, 
which  conducts  it  into  a  sanitary  bucket  underneath  the  table.  The 
relapsing  walls  of  the  emptying  cyst,  unless  prevented  by  adhesions, 
may  now  be  drawn  out  of  the  wound  with  the  fingers,  or  with  large 
cyst  forceps.  The  assistant  should  press  together  the  abdominal  walls, 
which  will  aid  in  the  expulsion  of  the  cyst  contents  and  at  the  same 
time  prevent  the  escape  of  intestines,  the  soiling  of  the  edges  of  the 
abdominal  wound  by  the  fluid  contents  of  the  cyst,  or  their  entering 
the  abdominal  cavity.  If  it  should  be  a  multilocular  cyst,  its  various 
compartments  may  be  emptied  by  passing  the  trocar  in  different  direc- 
tions. If  this  does  not  succeed  in  reducing  the  size  of  the  tumour 
sufficiently,  the  hand  may  be  passed  into  an  enlarged  opening  and  these 
various  compartments  ruptured  with  the  fingers.  The  hand,  upon 
withdrawal,  may  bring  the  collapsed  tumour  sac  along  with  it.  It  is 
wise  to  keep  tiio  opening  in  the  cyst  wall  always  outside  the  abdom- 
42 


642  A  TEXT-BOOK  OF  GYNECOLOGY 

iual  cavity  in  order  to  prevent  the  soiling  and  infection  of  the  peri- 
toneum by  any  colloid^,  dermoid,  or  other  infecting  material  which  it 
would  be  exceedingly  difficult  to  wash  out. 

Adhesions  of  the  Cyst  and  Ligation  of  the  Pedicle. — Any  adhesions, 
which  may  exist  will  come  into  view  as  the  empty  sac  is  withdrawn. 
Those  wliich  are  recent  and  the  result  of  inflammation  can  be  easily 
pressed  off  with  a  sjjonge,  or  separated  with  the  fingers.  Older  and 
firmer  adhesions,  which  are  likely  to  contain  blood  vessels,  should 
be  ligated  in  two  places  with  fine  silk  or  catgut,  and  cut  between  the 
ligatures  with  the  scissors.   ■ 

Adhesions  of  the  omentum  are  generally  vascular,  and  bleeding- 
surfaces  which  are  not  controlled  by  exposure  to  the  air  or  sponge 
pressure,  may  require  ligation.  When  the  cyst  wall  is  adherent  to- 
the  intestine,  or  can  not  be  readily  peeled  off,  a  portion  of  it  may  be 
left  attached,  rather  than  to  run  the  risk  of  laceration  by  its  forced  sepa- 
ration. Should  an  opening  be  made  in  the  intestine,  it  should  be 
immediately  closed  with  fine  silk.  There  are  fewer  incomplete  opera- 
tions now  than  formerly.  It  is  generally  estimated  that  the  mortality 
is  greater  where  circumstances  seem  to  require  that  the  operation  be 
left  uncompleted,  than  where  we  are  able  to  make  a  thorough  re- 
moval of  the  tumour  and  toilet  of  the  peritoneum,  even  in  our  worst 
cases. 

The  ancient  custom  of  Sir  Spencer  Wells,  and  many  other  distin- 
guished ovariotomists,  in  their  day,  of  clamping  the  ovarian  pedicle 
upon  the  outside  of  the  abdomen  is  no  longer  practised.  Clamps 
have  been  superseded  by  the  ligature,  the  cautery,  or  the  angeiotribe, 
according  to  the  preference  of  the  operator.  (See  Hemostasis.)  In 
each  case,  the  constricted  or  seared  stump  is  dropped  back  into  the 
peritoneal  cavity,  and,  in  all  cases  where  drainage  is  not  required,  the 
abdominal  wound  is  completely  closed.  While  an  assistant  holds  up 
the  empty  sac  or  delivered  tumour,  the  operator  transfixes  the  pedicle 
as  near  as  possible  to  the  uterus  with  a  long-handled,  dull-pointed 
needle,  threaded  at  the  point  with  pure  Chinese  silk  or  catgut, 
according  to  his  preference,  and  thus  securely  constricts  the  vessels. 
and  tissues  in  the  pedicle.  When  doubt  exists  as  to  perfectly  safe 
constriction,  the  ligature  is  brought  around  the  entire  mass  and  se- 
curely tied  again,  thus  shutting  olf  any  possibility  of  subsequent  hem- 
orrhage. A  figure-of-eight  or  a  Staffordshire  knot,  when  properly 
applied  is  equally  safe.  Taber  Johnson  still  retains  his  preference  for 
pure  Chinese  silk  ligatures  for  the  pedicle.  They  very  rarely  become 
infected  or  make  any  trouble.  Many  more  accidents  have  resulted 
from  the  relaxing,  untying,  or  slipping  off,  of  catgut  ligatures,  and 
from  sepsis  caused  by  imperfectly  prepared  catgut,  than  from  silk. 
Some  surgeons,  however,  are  very  enthusiastic  in  regard  to  the  use  of 
catgut  when  sterilized  in  solutions  of  cumol  or  formalin.  Eecently, 
Skene,  of  Brooklyn,  has  recommended  an  electro-cauterization  of  the 
pedicle  instead  of  ligatures,  and  still  more  recently  the  angeiotribe 


NEOPLASMS  OP   THE   OVARIES  643 

has  been  recommended  as  a  safe  and  proper  substitute  for  all  other 
means  of  treating  the  pedicle.  If  we  meet  with  a  pedicle  especially 
broad  and  thick,  it  may  require  ligation  in  several  places,  making 
what  is  called  a  chain  ligature. 

In  cutting  off  a  tumour  above  the  point  of  constriction,  a  button 
of  tissue  should  be  left,  sufficiently  large  to  prevent  the  possibility  of 
the  slipping  off  of  whatever  ligature  is  used. 

Minor,  of  New  York,  has  described  a  variety  of  tumour  in  the 
broad  ligament,  which  has  no  pedicle  whatever,  and  has  taught  us  Iioav 
to  enucleate  it  with  safety  from  the  tissue  in  which  it  lies  embedded, 
ligating  separately  any  bleeding  vessels  which  are  discovered. 

After  the  removal  of  an  ovarian  tumour,  the  other  ovary  should 
be  examined  also;  if  found  healthy,  it  should  be  let  alone.  If  the 
ovary  is  found  somewhat  diseased,  every  "  conservative  "  effort  should 
be  made  to  preserve  whatever  portion  of  it  can  be  properly  left  to 
perform  its  usual  function.  The  subsequent  condition  of  the  patient 
will  be  much  more  nearly  normal  if  sufficient  ovarian  tissue  is  pre- 
served to  keep  up  the  menstrual  molimen,  and  thus  to  prevent  a 
premature  occurrence  of  the  change  of  life,  with  all  that  that  implies. 

The  Toilet  of  the  Peritoneum. — In  those  cases  in  which  a  simple 
ovarian  tumour  has  been  removed  without  rupture  or  spilling  its  con- 
tents into  the  abdominal  cavity,  very  little  in  the  way  of  a  "  toilet " 
is  required;  the  less  manipulation  of  the  intestines  and  exposure  of 
the  abdominal  contents  the  better.  Even  the  small  sponge,  held  in 
the  grasp  of  a  long-handled  forceps,  which  is  usually  passed  down  into 
the  pelvic  cavity  in  search  of  blood  or  other  fluids,  may  frequently  be 
omitted,  and  the  omentum  carefully  drawn  down  over  the  intestines 
and  the  wound  closed.  In  those  cases  where  the  omentum  has  been 
lacerated  or  torn  in  separating  adhesions,  if  there  is  any  evidence 
of  bleeding,  it  should  be  carefully  drawn  out  of  the  wound,  spread  over 
hot  sterilized  towels,  and  the  bleeding  points  sought  out  and  ligated. 
In  most  cases,  simple  oozing  can  be  arrested  by  hot  water  or  hot 
sponge  pressure.  If  some  portion  of  the  omentum  is  considerably 
lacerated,  a  ligature  may  be  applied  behind  the  leaking  surfaces  and 
the  omentum  tissue  boldly  cut  away.  In  those  cases  where  there  has 
been  much  hemorrhage  from  tissues  lacerated  by  the  separation  of 
adhesions,  or  the  abdominal  cavity  has  been  soiled  and  possibly  in- 
fected by  fluids  from  malignant  tumours,  or  by  pus  from  infected 
abscesses,  the  cavity  should  be  thoroughly  irrigated  with  hot  normal 
salt  solution.  In  that  class  of  cases  which  have  heretofore  required 
transfusion,  large  quantities  of  the  normal  salt  solution  may  be 
poured  into  the  abdominal  cavity  and  left  there  to  float  the  intestines, 
to  prevent  the  immediate  occurrence  of  adhesions,  and  to  perform  the 
office  of  transfusion  Ijy  being  absorbed  into  the  circulation.  The 
great  thirst  which  usually  follows  ovariotomy,  as  well  as  all  other 
abdominal  operations,  is  much  alleviated  by  the  salt  solution.  ISTo 
germicide  of  siifllcient  strength  to  be   of  any  service   in   destroying 


6M  A  TEXT-BOOK   OF  GYNECOLOGY 

germs  is  ever  permissible  inside  the  abdominal  cavity.  If  it  were  suf- 
ficiently powerful  to  kill  the  germs,  it  would  at  the  same  time  kill 
the  patient. 

General  irrigation  of  the  abdominal  cavity  is  not  employed  at  the 
present  day  as  frequently  as  it  was  formerly.  A  localized  collection 
of  infectious  fluid,  readily  absorbed  by  a  sponge,  might  be  carried  to 
remote  parts  of  the  cavity  by  general  irrigation  and  set  up  an  incur- 
able septic  peritonitis.  The  abdominal  wound  may  be  closed  by  what 
have  been  described  as  through-and-through  sutures,  or  the  tissues  may 
be  brought  together  by  from  three  to  six  tiers  of  sutures  according  to 
the  preference  of  the  operator.  When  the  through-and-through  sutures 
are  used,  four  to  the  inch  should  be  emplo^'ed.  The  object  of  the  more 
thorough  suturing  is  the  more  sure  prevention  of  ventral  hernia.  Taber 
Johnson  doubts  whether  half  a  dozen  layers  of  sutures  accomplish  this 
purj)ose  more  thoroughly  than  well-applied  through-and-through  su- 
tures. From  the  investigations  which  he  has  been  able  to  make, 
about  the  same  number  of  cases  of  ventral  hernia  occur  with  one 
method  as  with  another.  As  ventral  hernia  will  be  prevented  by  per- 
fect union  of  the  fascia,  after  the  application  of  the  through-and- 
through  sutures  Taber  Johnson  is  in  the  habit  of  inserting  one  silk- 
worm gut  to  the  inch  through  the  edges  of  the  fascia,  and  thus  secur- 
ing permanent  approximation  of  its  edges  when  tied.  If  union  fails 
to  occur,  these  nonabsorbable,  buried  sutures  will  hold  it  together  for- 
ever.   Some  operators  prefer  silver  wire  for  this  j)urpose. 

If  a  fixed  rule,  alwa^-s  to  close  the  abdominal  wound  with  five  or  six 
layers  of  sutures,  is  adopted,  the  operator  will  not  infrequently  find 
himself  spending  more  time  over  the  closing  of  the  abdominal  wound 
than  over  all  the  other  steps  of  the  operation  together. 

Drainage. — The  present  practice  of  ovariotomists  is,  so  far  as 
possible,  to  avoid  drainage.  I^^ot  a  few  gynecological  surgeons  have 
recently  reported  that  they  have  not  drained  the  abdomen  after  ovari- 
otomy for  a  number  of  years,  even  in  their  worst  cases,  and  that  they 
find  no  increase  in  their  mortality.  In  those  cases  where  drainage 
is  considered  absolutety  necessary  on  account  of  the  soiling  of  the 
peritoneum  with  infectious  fluid,  gauze  drainage  is  used  much  more 
frequently  than  the  glass  tubes.  jSTeither  the  glass  tube,  nor  gauze 
drainage,  is  likely  to  be  of  much  service  after  twenty-four  hours;  for 
the  glass  tube  does  not  drain  any  greater  area  than  the  little  pocket 
at  its  distal  extremity,  on  account  of  its  being  shut  off  from  the 
abdominal  cavity  by  lymph  which  has  been  poured  out  around  it ; 
while  gauze,  after  it  has  once  become  wet,  ceases  to  absorb  more  fluid, 
and  only  drains  by  lying  in  contact  with  dry  gauze  which  may  absorb 
from  it. 

Dressings. — The  dressings  applied  to  an  ovarian  wound  need  hardly 
differ  from  those  applied  after  any  up-to-date  aseptic  operation.  The 
practice  of  dusting  iodoform  powder  over  the  edges  of  the  wound  has 
been    abandoned.     The    wound    should    be    thoroughly    dried    and 


NEOPLASMS  OF   THE   OVARIES  645 

cleansed,  and  pads  of  gauze  placed  on  each  side  of  the  row  of  sutures, 
and  another,  thicker  gauze  pad  laid  over  them  both.  A  combined 
dressing  is  then  applied  over  the  abdomen  from  hip  to  hip  and  secured 
by  broad  strips  of  adhesive  plaster.  A  thin  flannel  or  many-tailed 
bandage  may  now  be  applied,  securely  holding  the  dressings  perma- 
nently in  position.  These  do  not  require  to  be  changed  for  seven  days, 
if  all  goes  well.  If  the  tumour  has  been  very  large  and  the  abdom- 
inal walls  have  sunk  in  considerably,  the  depressed  spaces  should  be 
filled  out  by  sterilized  absorbent  cotton. 

After-treatment. — The  after-treatment  of  a  simple  case  of  ovari- 
otomy amounts  to  little  more  than  keeping  the  patient  clean  and  let- 
ting her  alone.  Give  her  a  cheerful  nurse,  protect  her  from  visitors, 
and  encourage  her  to  get  well.  Little  medicine  is  required  beyond 
what  is  necessary  to  move  the  bowels,  quiet  restlessness,  and  produce 
sleep.  As  soon  as  the  patient  has  had  a  good  operation  from  the 
bowels  she  is  considered  convalescent.  This  is  usually  produced  by 
small  doses  of  calomel,  followed  by  teaspoonful  doses  of  Eochelle  salts 
every  two  hours  until  the  bowels  move.  It  was  formerly  the  custom 
to  withhold  all  food  or  drink  for  twenty-four  hours.  The  piteous 
appeals  of  the  patient  for  water  to  quench  her  thirst  were  stubbornly 
resisted,  but  we  find  by  increasing  experience  that  patients  may,  with- 
out injury  and  greatly  to  their  comfort  and  happiness,  take  frequent 
sips  of  hot  water  or  tea  a  few  hours  after  their  recovery  from  the 
ansesthetic,  unless  tormented  by  the  ether  nausea.  Patients,  it  is 
found,  may  also  take  with  benefit  small  draughts  of  beef  essences  or 
concentrated  forms  of  liquid  nourishment  after  the  first  twelve  hours. 
If  this  disagrees  with  them,  it  should  be  withheld  for  a  while.  It  is 
best  to  adhere  to  the  rule  that  patients  should  not  see  visitors  for  a 
week  after  their  operation.  Exceptions  will  occur  where  a  discreet 
mother  or  husband  may  see  the  patient  a  few  days  after  her  opera- 
tion with  great  benefit.  The  patient  should  be  urged  to  pass  her 
water  in  a  bedpan.  The  use  of  the  catheter  in  the  hands  of  the  most 
skilful  nurse  has  often  produced  urethral  or  vesical  irritation.  Its 
routine  use  for  several  days  after  all  ovariotomies  should  be  aban- 
doned. 

The  use  of  opium  should  be  avoided  when  possible,  as  the  patient's 
pain,  nervousness,  and  restlessness,  are  generally  increased  and  pro- 
longed by  the  unwise  use  of  this  drug.  There  will  occur,  now  and 
then,  a  ease  where  a  hypodermic  of  morphine  or  codeine  will  quiet 
restlessness  and  produce  the  greatest  amount  of  comfort,  with  no 
harm  whatever  following  its  use ;  but  the  routine  employment  of  opi- 
ates after  ovariotomy  is  full  of  mischief  and  trouble. 

If  the  bowels  are  painfully  distended  by  collections  of  gas,  the 
introduction  of  a  rectal  tube  gives  much  relief.  If,  upon  removal  of 
the  dressing  on  the  seventh  day,  the  wound  is  found  well  united,  the 
sutures  may  be  all  gently  removed.  If  union  is  not  perfect,  or  if 
stitch-hole  abscesses  have  occurred,  a  few  of  the  stitches  can  be  left 


646  A  TEXT-BOOK  OF  GYNECOLOGY 

for  two  or  three  days  longer.  If  the  wound  is  perfectly  dry,  no  treat- 
ment is  necessary,  but  narrow  strips  of  rubber  plaster  may  be  placed 
across  the  wound  to  hold  it  securely  while  a  firmer  union  is  taking 
place.  The  gauze  dressings  should  be  changed  and  held  in  position  by 
a  firm  clean  binder. 

It  is  better  for  the  patient  to  remain  in  bed  three  weeks.  Young, 
vigorous  patients,  who  have  had  an  uninterrupted  recovery,  have  gone 
home  from  the  hospital  at  the  end  of  two  weeks  without  harm,  but 
this  is  not  a  safe  practice.  If  no  pus  is  present,  the  wound  may  not 
require  dressing  oftener  than  once  a  week.  At  the  end  of  the  fourth 
week,  the  patient  may  safely  be  allowed  to  return  to  her  home,  but 
should  be  provided  with  an  abdominal  bandage,  which  she  should  be 
advised  to  wear  for  six  months  or  a  year,  and  to  abstain,  so  far  as  pos- 
sible, from  overwork,  lifting  heavy  weights,  or  any  straining  occupa- 
tion which  might  have  a  tendency  to  produce  ventral  hernia. 

Accidents. — Accidents  may  occur  during  ovariotomy  from  the  ad- 
ministration of  the  anaesthetic,  or  from  the  stripping  ofE  of  the  peri- 
toneum from  the  abdominal  walls  or  the  intestines.  The  cyst  wall 
may  be  accidentally  ruptured  while  separating  adhesions.  Bleeding 
points  may  be  overlooked,  and  the  patient's  life  lost  from  hemor- 
rhage after  the  closure  of  the  incision.  Ligatures  have  slipped  off  the 
pedicle,  catgut  has  become  untied;  intestines,  omentum,  or  bladder, 
have  been  injured  when  opening  the  abdominal  cavity,  or  torn  while 
separating  adhesions.  None  of  these  accidents  should  occur  in  the 
hands  of  the  average  conscientious  operator.  Sponges,  forceps,  scissors, 
rings,  and  eyeglasses,  have  all  been  lost  in  the  abdominal  cavity  during 
an  operation,  and  have  been  searched  for  subsequently  or  found  during 
a  post-mortem. 

Obstruction  of  the  bowels  may  be  caused  by  paralysis  of,  or  kinks 
or  twists  in,  the  intestines.  Fistulas  may  follow  the  use  of  infected 
ligatures,  and  ventral  hernia  may  occur  to  torment  the  patient  in 
some  cases  to  such  an  extent,  that  her  sufferings  are  greater  after  her 
operation  than  they  were  from  the  condition  which  made  the  opera- 
tion necessary. 

Mortality. — The  average  mortality  at  the  hands  of  all  operators 
the  world  over,  is  probably  about  10  per  cent.  Experts  in  the  prin- 
cipal cities  of  the  world  will  often  report  a  series  of  100  cases,  how- 
ever, with  no  mortality  whatever.  Leaving  out  the  cases  of  malig- 
nancy and  the  unexpected  accidents,  the  mortality  of  ovariotomy  in 
the  hands  of  experienced  operators  will  probably  not  range  above  3  or 
5  per  cent,  while  during  the  first  half  of  the  present  century  the  mor- 
tality lingered  very  closely  around  50  per  cent.  We  are  proud  and 
happy  to  state  that  as  fhe  new  century  is  dawning  the  mortality  is 
reduced  to  less  than  5  per  cent. 

Incomplete  Ovariotomy. — This  is  sometimes  made  necessary  by  the 
character  of  the  growth,  and  by  the  extent  and  density  of  its  adhe- 
sions.    Proliferating  cysts,  the  pedicles  of  which  have  been  subjected 


NEOPLASMS  OF  THE   OVARIES  647 

to  even  temporary  torsion,  exposed  to  traumatism  or  infection,  or  have 
become  the  seat  of  secondary  malignant  changes,  may  become  so 
intimately  involved  with  the  intestines  that  they  can  not  be  removed 
without  irreparable,  if  not  fatal,  injury  to  the  latter.  Under  such 
circumstances,  it  may  be  found  expedient  to  remove  a  part  of  the  cyst 
wall,  stitching  the  remainder  to  the  margins  of  the  intestinal  incision, 
an  operation  which  Pozzi  designates  as  the  marsupialization  of  the 
patient.  It  is  always  a  matter  of  great  importance  to  determine  when 
this  step  should  be  taken.  As  a  rule  exemplified  in  the  reported  cases 
of  Vander  Veer  {New  YorJc  Medical  Journal,  1893),  it  should  be  done 
in  the  presence  of  the  foregoing  complications,  particularly  when  the 
operation  has  already  been  so  long  or  so  difficult  that,  if  still  further 
prolonged,  the  patient  will  die  from  hemorrhage  or  shock.  In  fixing 
the  edges  of  the  sac  to  the  edges  of  the  abdominal  wound,  it  is  impor- 
tant to  see  that  all  bleeding  points  in  the  former  are  brought  under 
control.  This  can  be  accomplished,  as  a  rule,  by  means  of  ligatures; 
but  in  exceptional  cases,  the  cyst  walls  will  be  found  to  be  of  such  an 
embryonic  character  that  they  wilj  not  sustain  a  ligature,  when  it  will 
become  necessary  to  resort  to  the  cautery,  to  styptics,  or  to  sponge 
packing,  to  control  the  bleeding.  Cases  have  been  reported  in  which 
the  remnant  of  tumour  tissue  has  sloughed  away  through  the  opening 
left  by  this  operation,  the  patient  making  an  eventual  recovery.  For- 
tunately, complications  rendering  this  course  necessary  are  now  of 
relatively  rare  occurrence. 

Ovariotomy  during  Pregnancy. — This  is  frequently  an  operation 
of  expediency.  The  mortality  from  this  operation,  if  done  during 
the  first  five  or  six  months  of  pregnancy,  is  not  higher  than  when  done 
in  a  nonpregnant  state.  Olshausen  has  performed  the  operation  26 
times  without  a  single  death.  The  danger  to  both  mother  and  child 
increases  with  the  progress  of  gestation.  The  results  are  most  fa- 
vourable for  the  mother  in  the  second,  third,  and  fourth  months,  and 
for  the  child  in  the  third  and  fourth  months — although  favourable 
results  are  obtained  even  in  the  last  month  of  gestation.  The  liability 
to  rupture  renders  ovariotomy  the  desirable  alternative  at  any  stage 
of  pregnancy.  "  Palliative  "  treatment  by  puncture  of  the  cyst  does  not 
palliate;  on  the  contrary  the  cyst  rapidly  refills,  with  an  increased 
tendency  to  adhesion  and  rupture. 

Successful  cases  of  double  ovariotomy  during  pregnancy  have  been 
reported  by  Vander  Veer,  Knowsley  Thornton,  Gardner,  Montgomery, 
Munde,  Potter,  Bovee  and  others.  Potter's  case,  reported  to  the 
American  Association  of  Obstetricians  and  Gynecologists  (vide  Trans- 
actions, 1888),  was  probably  the  first  case  in  America  in  which  a 
woman  went  to  full  term  after  a  double  ovariotomy  done  during  the 
course  of  gestation.  In  this  case.  Potter  operated  in  the  latter  part 
of  the  fourth  month;  there  was  a  tendency  to  rhythmic  uterine  con- 
tractions on  the  seventh  day,  but  these  speedily  subsided,  after  which 
she  wont  to  full  tortn  without  incident.    These  cases  must  be  accepted 


648 


A  TEXT-BOOK  OF  GYNECOLOGY 


as  establishing  the  safety  of  the  operation — although  the  liability  of  a 
double  ovariotomy  to  induce  abortion  must  be  considered  as  greater 
than  that  which  pertains  to  the  operation  upon  one  side  only. 

The  results  of  ovariotomy  during  pregnancy  are  favourable. 
Dsirne  reports  135  cases  with  8  deaths,  being  a  mortality  of  5.9  per 
cent.  Subsequent  reports  from  individual  operators  do  not  tend  to- 
increase  the  mortality.  The  influence  of  ovariotomy,  under  these  cir- 
cumstances, upon  pregnancy,  has  been  ascertained  with  approximate 
accuracy.  Olshausen  found  pregnancy  interrupted  in  about  20  per 
cent  of  his  cases.  While  Dsirne  (Archiv  fur  Gynakologie)  found  that 
it  was  interrupted  in  22  per  cent  of  114  cases  which  he  collected.  This 
seemed  to  vary  somewhat  according  to  the  stage  of  gestation,  as  indi- 
cated by  the  following  table  by  Dsirne  : 


At  Months. 

No.  cases. 

Interruptions  of 
pregnancy. 

Percentage. 

2 

11 

28 

21 

10 

11 

5 

5 

1 

5 

4 
2 
4 
4 
3 
3 
1 

45.5 

3 

14.3 

4. .           

9.5 

5 

6 

40.0 
36.4 

7 

60.0 

8 

40.0 

9 

100.0 

Bovee  {American  Journal  of  Obstetrics)  has  tabulated  23  cases  in 
which  extirpation  of  the  uterine  appendages  has  been  practised  in  the 
presence  of  pregnancy.  Ten  of  the  cases  were  for  ovarian  cyst,  while  in. 
8  out  of  the  10,  the  cysts  were  double;   all  the  patients  recovered. 


CHAPTEli    XLII 

ECTOPIC   PREGNANCY 

Historical  resume — Definition — Etiology — Classification — Course  and   termination 
— Histology — Symptomatology — Diagnosis — Treatment. 

Historical  Resume.^ — The  term  ectopic  pregnacy,  from  e/croTros  (Ik, 
out  of,  and  tottos,  a  place),  was  suggested  by  Dr.  Robert  Barnes  in 
lieu  of  the  familiar  term  extrauterine  pregnancy,  to  designate  a  mal- 
position of  the  fertilized  ovum.  It  has  been  very  generally  accepted 
into  gynecological  nomenclature  as  more  accurately  designating  the 
pathology  of  this  most  interesting  condition.  Since  the  fertilized 
ovum  may  be  arrested  and  may  develop  in  that  portion  of  the  tube 
passing  through  the  uterine  walls,  it  is  ap|)arent  that  such  a  pregnancy 
would  not  be  extrauterine  but  ivould  be  ectopic. 

This  pathologic  condition  until  recently  constituted  a  dark  chapter 
in  gynecological  surgery.  It  was  altogether  misunderstood  in  its 
etiology  and  pathology,  its  symptoms  were  misinterpreted,  and  hun- 
dreds of  deaths  occurred  annually  which  would  now  be  prevented  by 
timely  surgical  intervention.  Following  the  possibilities  of  aseptic 
surgery,  this  great  achievement  was  accomplished  by  one  man,  Lawson 
Tait,  whose  genius  illumined  the  entire  subject  and  established  meth- 
ods of  cure  that  approach  perfection.  The  first  correct  interpretation 
of  the  pathology  of  this  abnormity,  which  has  such  heavy  mortality, 
was  attained  by  Bernutz  and  Goupil,  two  able  French  observers  who 
have  made  an  exhaustive  study  of  the  disease  by  post-mortem  exami- 
nation. The  work  of  these  eminent  students  of  pathology  was  trans- 
lated into  English  in  1866  and  widely  circulated  under  the  auspices 
of  the  New  Sydenham  Society  by  Alfred  Meadows.  The  work  was 
ably  reviewed  in  America  at  great  length  by  Parvin,  yet  no  surgeon 
adopted  the  true  pathology  of  extrauterine  pregnancy  as  therein  set 
forth.  John  S.  Parry,  of  Philadelphia,  made  a  valuable  contribution 
to  the  subject  in  a  book  published  in  1876,  but  did  not  elucidate  the 
pathology  or  recognise  the  surgical  aspects  involved  when,  through 
the  advance  of  aseptic  surgery,  it  became  practicable  to  open  the  abdo- 
men with  safety  for  the  relief  of  grave  and  obscure  intra-abdominal 
disease.  Tait  dealt  with  the  subject  in  a  masterly  way.  Utilizing  the 
post-mortem  researches  of  Bornutz  and  Goupil  and  the  clinical  obser- 
vations of  Parry,  he  eluciflatod  the  entire  subject,  classified  its  various 
types  and  pliases,  and   fonniilaicd  iind  dcnionstrated  with  the  mind 

649 


650  A  TEXT-BOOK  OP  GYNECOLOGY 

of  a  genius  and  the  hand  of  a  master,  therapeutic  resources  which  have 
placed  his  name  forever  among  the  benefactors  of  science  and 
humanit}'. 

Definition. — The  term  ectopic,  or  extrauterine,  pregnancy  is,  as 
already  stated,  applied  to  a  malposition  and  abnormal  development  of 
the  fertilized  ovum.  After  fertilization  the  ovum  may  establish  its 
habitat  within  the  ovary  (ovarian  pregnancy),  within  any  part  of  the 
free  Fallopian  tube  (tubal  pregnancy),  or  witliin  that  portion  of  the 
tube  which  passes  through  the  uterine  wall  at  the  cornu  (interstitial 
pregnancy).  Primarily,  ectopic  pregnancy  is  almost  invariably  situ- 
ated in  the  Fallopian  tube,  and  ovarian  pregnancy  is  so  very  rare  that 
its  existence  has  been  denied  both  by  pathologists  and  surgeons. 
However,  specimens  have  been  studied  carefully  by  competent  observ- 
ers, which  establish  the  fact  that  this  anomaly  actually  does  occur; 
but  the  instances  are  so  few  as  to  render  ovarian  pregnancy  an  ex- 
treme rarity  in  clinical  experience.  Ectopic  pregnancy,  as  a  rule,  is 
tubal. 

Etiology. — In  considering  the  etiology  of  ectopic,  or,  preferably, 
tubal  pregnancy,  it  is  necessary  to  review  to  some  extent  the  physiology 
of  the  Fallopian  tube  and  the  impregnation  of  the  ovum.  The  tubes  are 
the  ducts  through  which  the  ovum,  when  discharged  from  the  ovary, 
travels  into  the  uterine  cavity;  hence  their  name,  oviducts.  From 
observations  and  experiments  made  on  the  lower  animals,  it  appears 
probable  that  the  transport  of  the  ovum  is  effected  mainly,  if  not  ex- 
clusively, through  the  action  of  the  ciliated  columnar  epithelium  lining 
the  tubal  mucous  membrane.  It  is  quite  probable  that  peristaltic 
movements  of  the  tubes,  if  they  take  any  part  at  all  in  the  transport  of 
the  ovum,  play  a  minor  role  only.  We  have  every  reason  to  believe  that 
in  the  human  being,  as  is  the  case  in  some  of  the  lower  animals,  judg- 
ing from  observations  actually  made,  the  fertilization  of  the  ovum  by 
the  spermatozoa  occurs  in  the  outer  half  or  outer  third  of  the  tube. 
Normally,  an  ovum  fertilized  in  the  tube  will,  in  a  few  days,  travel 
jnto  the  uterine  cavit}^  and  will  there  become  implanted  for  further 
development.  The  question  arises.  What  cause  or  causes  are  respon- 
sible for  an  impregnated  ovum  remaining  and  becoming  implanted  in 
the  tube,  instead  of  passing  into  the  uterus?  Certain  alleged  causes, 
formerly  frequentl}''  cited  as  responsible  for  tubal  pregnancy,  such 
as  inflammatory  diseases  of  the  uterus  and  tubes,  must  be  absolutely 
discarded.  We  know  now  that  these  very  conditions,  instead  of  being 
the  cause  of  tubal  pregnancy,  make  a  woman  sterile  for  the  time 
being,  and  therefore  exclude  tubal,  as  well  as  normal  uterine  preg- 
nancy. It  is  impossible  here  to  go  into  a  discussion  of  all  the  alleged 
causes  of  tubal  pregnancy,  since  most  of  them  really  deserve  detailed 
consideration.  Herzog,  who  has  carefully  studied  the  gross  and  fine 
anatomy  of  over  30  cases  of  tubal  pregnancy,  believes  that,  in  a  con- 
siderable proportion,  congenital  anomalies  of  the  tubes  must  be  held 
responsible  for  the  establishment  of  an  ectopic  gestation.    Herzog  has 


ECTOPIC   PREGNANCY  651 

certainly  twice,  and  possibly  three  times,  seen  tubal  pregnancy  in  a 
diverticulum  of  the  main  canal  (Fig.  277),  and  once  in  an  accessory 
blind  fimbriated  extremity.  (Henrotin  and  Herzog.  Anomalies  du 
Canal  de  Miiller,  comme  cause  de  grossesse  ectopique.  Revue  de 
chirurgie  abdominale,  1898. — Henrotin  and  Herzog.  Very  Early 
Eupture  in  an  Ectopic  Pregnancy  in  a  Diverticulum,  New  York  Med- 
ical Journal,  1899.)     Several  times  he  noticed  that  the  tubal  canal  in 


Fig.  277. — "  A  diverticulum  of  the  main  canal." — Heuzog. 

which  the  pregnancy  occurred  was  unusually  tortuous,  so  that  the 
road  from  the  fimbriated  extremity  to  the  ostium  internum  of  the 
tube,  which  the  ovum  would  have  to  traverse,  was  an  unusually  long  one. 
The  theory  that  congenital  anomalies  are  the  cause  of  tubal  pregnancy 
is  supported  by  facts. 

Another  cause  assumed  by  Herzog  can  not  yet  be  supported  by 
direct,  actual  observations.  He  is  of  the  opinion  that  the  tubal  mu- 
cosa takes  part  to  a  certain  extent  in  menstruation.  ISTormally,  the 
menstrual  changes  of  the  tubal  mucosa  are  insignificant,  compared 
with  those  of  the  uterine  mucosa.  Occasionally,  however,  the  tubal 
mucous  membrane  shows  intense  menstrual  changes,  which  may  be  so 
pronounced  as  to  lead  to  the  formation  of  a  hematosalpinx.  We  can 
hardly  doubt  that  the  menstrual  changes  of  the  uterine  mucosa  pre- 
pare the  latter  for  the  reception  of  an  impregnated  ovum,  which,  as 
appears  most  probable  from  the  latest  contributions  upon  the  sub- 
ject, eats  or  corrodes  its  way  into  the  substance  of  the  uterine  mucosa 
by  the  aid  of  a  phagocytic  trophoblast  (see  page  657).  Whenever 
the  tubal  mucous  membrane  undergoes  extensive  menstrual  changes, 
it  must  become  a  soil  into  which  an  impregnated  ovum  can  easily 
implant  itself.  It  therefore  appears  very  probable  to  Herzog  that 
such  well-marked  menstrual  changes  in  the  tubal  mucosa  frequently 
become  the  cause  of  an  ectopic  implantation  of  a  fertilized  ovum. 

So  far  as  our  exact  knowledge  goes  to-day,  we  must,  however,  con- 
fess that  we  are  unable  in  most  cases  of  ectopic  gestation  definitely  to 
give  the  exact  causes  of  this  occurrence,  often  so  very  grave  in  its 
conseqnoTices.  That  our  knowledge  as  to  the  etiology  of  most  cases 
of  ectopic  gestation  is  yot  so  very  deficient,  lies  in  the  very  circum- 


652 


A  TEXT-BOOK   OF  GYNECOLOGY 


stances  surrounding  this  occurrence.  In  addition,  we  must  not  forget 
that  when  we  obtain  a  specimen  for  examination  post  operationem  or 
post  mortem,  hemorrliages  and  secondary  changes  have  often  so 
mutilated  the  parts  that  exact  anatomical  studies  frequently  become 
utterly  impossible. 

Classification. — The  varieties  of  tubal  pregnancy,  which  are  distin- 
guished according  to  the  anatomical  seat  of  the  developing  ovum,  are 
as  follows :  If  the  ovum  is  in  the  part  of  the  tubal  canal  which  per- 
forates the  uterine  wall,  we  speak  of  it  as  an  interstitial  pregnancy. 
This  variety  is  not  very  frequently  seen.  There  have  been  reported 
erroneously  as  interstitial  pregnancies,  cases  which  were  cornual  or 
where  the  ovum  was  located  in  a  blind  prolongation  of  Gartner's  duct, 
which  sometimes  extends  down  into  the  cervix.  In  interstitial  tubal 
pregnancy,  the  developing  ovum  frequently  pushes  its  way  into  the 
uterine  cavity,  and  we  then  have  the  condition  known  as  tuho-uterine 
gravidity.  In  it,  the  gestation  sac  may  be  of  fair  thickness,  and  the 
pregnancy  may  go  on  to  full  term  and  terminate  fairly  normally. 

The  second  vari- 
ety of  tubal  preg- 
nancy is  present 
when  the  ovum  is 
found  in  the  middle 
part  of  the  tube;  in 
Avhich  case  we  are 
dealing  Avith  an  istJi- 
niic  tubal  pregnancy, 
or  tubal  pregnancy 
par  excellence  {gravi- 
ditas tubaria  pro- 
pria). The  placenta 
in  these  cases  gener- 
ally has  its  seat  in 
the  lower  or  poste- 
rior part  of  the  tube 
wall.  The  gestation 
sac  in  this  variety  is 
generally  very  thin 
and  the  danger  of 
rupture  very  great. 
Here  we  also  some- 
times find  peduncu- 
lated gestation  sacs. 

Probably  the  most 
frequent    variety    is 
that  of  a  development  of  the  ovum  in  the  outer  third  of  the  tube  or  am- 
pulla.   This  kind  of  ectopic  gestation  is  known  as  ampullar  pregnancy. 
The  widest  part  of  the  Fallopian  tube,  the  ampulla,  naturally  offers  the 


Fig.  27£ 


-The  case  [of  ectopic  pregnancy]  of  Joseph  Price. 
— PlERzoa  (page  653). 


ECTOPIC   PREGN^AXCY 


653 


most  favourable  conditions  for  an  undisturbed  development  of  an  im- 
planted ovum.  So  we  frequently  find  ampullar  pregnancy  develop  much 
beyond  the  earlier  months  of  gestation.  On  the  other  hand,  the  funnel- 
shaped  amjDulla  favours  abortion  of 
the  ovum.  The  latter  sometimes 
partly  protrudes  out  of  the  ampulla 
into  the  general  peritoneal  cavity,  and 
then  we  have  the  condition  known  as 
tuho-abdominal  pregnancy.  This  is, 
however,  not  the  rule,  but  the  excep- 
tion in  ampullar  pregnancy,  because 
there  exists  already  in  the  earlier 
months  a  tendency  of  the  fimbriated 
extremity  to  become  closed  by  aggluti- 
nation of  the  plicae.  It  also  occurs 
that  the  ovum  in  ampullar  pregnancy 
protrudes  into,  and  partly  develops  in, 
cystic  j^ortions  of  the  ovary.  This 
condition  can  probably  supervene 
only  when,  early  in  the  course  of  or 
prior  to  ectopic  gestation,  the  fimbri- 
ated extremity  becomes  adherent  to 
the  ovary  and  forms  what  is  called  a 
tubo-ovarian  cyst.  The  form  of 
ecoptic  gestation  then  established  is 
called  tubo-ovarian  pregnancy.  That 
primary  true  ovarian  pregnancy  occurs 

as  a  matter  of  fact,  is  demonstrated  by  well-authenticated  cases,  notable 
among  which  is  an  advanced  case  by  Price  (Figs.  378,  279)  in  which 
the  child  went  to  term,  projecting  on  either  side  from  the  enlarged 
ovary;  and  an  early  case  by  Withrow  (Fig. 
280),  the  fact  of  impregnation  in  the  latter 
having  been  established  by  careful  microscopi- 
cal studies  by  Whitacre.  Abdominal  and  in- 
traligamentous pregnancies  are  developed 
from  primary  tubal  gestation.  Intraligamen- 
tous pregnancy  may  be  brought  about  in  a  va- 
riety of  ways.  There  may  be  a  rupture  of  the 
lower  part  of  the  tube  wall  with  more  or  less 
hemorrhage  and  the  escape  of  the  ovum  be- 
tween the  folds  of  the  broad  ligament.  The 
growing  ovum  may  so  stretch  the  lower 
segment  of  the  tube  that  it  becomes  entirely 
membranaceous,  and  the  sac  so  formed  may 
unfohl  the  two  leaves  of  the  broad  ligament.  This  splitting  apart  of 
the  layers  may  also  be  brought  about  in  such  a  manner  that  the  ovum 
completely  rarefies  the  wall  of  the  Fallopian  tube  at  some  point,  and 


Fro.  •J.'~i'.). — "  Thu  chilli  went  to  tuna 
projecting  on  either  side  from  tlie 
enlarged  ovary." — Heezog. 


Fig.  280.  — "An  early  case 
by  Withrow." — IIekzog. 


654 


A  TEXT-BOOK  OF  GYNECOLOGY 


produces  a  slit  through  which  it  escapes  to  a  spot  between  the  folds  of 
the  broad  ligament  where  further  development  takes  place. 

Abdominal  pregnane}^  can  be  brought  about  in  a  variety  of  ways. 
An  ovum  located  in  the  tube  may  be  aborted  through  the  ostium 
abdominale  into  the  general  peritoneal  cavity.  If  its  placenta  is  not 
too  seriously  damaged,  the  embryo  may,  after  tubal  abortion,  go  on 
developing.  Rupture  of  the  tube  may  send  the  ovum  into  the  general 
abdominal  cavity.  The  embryo  may  continue  to  develop  not  only 
when,  after  primary  rupture,  its  membranes  are  intact,  but  even  after 
rupture  of  the  foetal  membranes  has  taken  place. 

Course  and  Termination  of  Ectopic  Gestation. — While  almost  every 
variety  of  ectopic  gestation  may  go  on  to  full  term,  most  cases  ter- 
minate in  the  earlier  months  of  development  by  rupture  or  abortion. 
Rupture,  in  the  majority  of  cases,  is  brought  about  by  preceding 
larger  or  smaller  hemorrhages.  The  latter  are  of  two  kinds:  small 
hemorrhages  from  enlarged  tubal  vessels  into  the  cedematous  and  in- 
flamed tube  wall,  and  hemorrhages  from  the  utero-placental  sinuses 
into  the  intervillous  space.  The  utero-placental  sinuses  in  tubal  preg- 
nancy are  opened  in  a  more  irregular  and  more  extensive  manner  by 
the  syncytium  than  is  the  case  in  normal  uterine  pregnancy,  and  the 

stretching  of  the  tube  wall  by  the 
enlarging  ovum  early  establishes  a 
tendency  to  extensive  hemorrhages 
from  the  utero-placental  sinuses 
into  the  intervillous  space.  These 
hemorrhages  frequently  dissect 
the  ovum  loose  from  the  gesta- 
tion sac,  and  rupture  is  often  initi- 
ated in  this  manner.  But  even 
if  a  rupture  does  not  occur,  the 
embryo  may  be  killed  and  the 
ovum  arrested  in  further  develop- 
ment in  consequence  of  the  in- 
tervillous or  interplacental  hemor- 
rhages. Herzog  examined  2  cases 
of  tubal  pregnancy  operated  on  before  rupture  had  occurred.  In  1 
case,  the  embryo,  about  five  weeks  old,  was  badly  macerated.  In 
the  other,  the  embryo,  from  seven  to  eight  weeks  old,  looked  per- 
fectly fresh  and  normal  (Fig.  281).  It  was  found,  however,  in  both 
cases  that  extensive  interplacental  hemorrhages  had  taken  place, 
and  that  the  villi  in  both  cases  were  badly  crushed  and  in  an 
advanced  stage  of  degeneration.  If  this  is  the  case,  the  embryo  de- 
pending for  its  nutrition  upon  the  villi  must,  of  course,  perish  in  a 
short  time.  Herzog  thinks  that  interplacental  hemorrhage  very  fre- 
quently precedes  rupture  for  quite  an  interval  of  time,  because  often, 
even  when  operation  is  performed  shortly  after  the  symptoms  of  rup- 
ture become  manifest,  one  finds  the  villi  in  an  advanced  state  of  de- 


FiG.  281.  —  "The  embryo,  from  seven  to 
eight  weeks  old,  looked  perfectly  fresh 
and  normal." — Herzog. 


ECTOPIC  PREGNANCY  655 

generation.  When  more  or  less  extensive  hemorrhage  occurs,  either 
into  the  tissues  of  the  tube  wall  or  into  the  intervillous  space,  rup- 
ture generally  takes  place  in  consequence  of  pressure.  The  hemor- 
rhage after  rupture  increases  as  a  rule  very  much,  and  it  may  become 
fatal.  The  rupture  generally  occurs  at  the  place  where  the  placenta 
has  been  attached.  Here,  the  tissues  of  the  tube  wall  are  often 
thinned  out  very  much.  The  cellular  elements,  particularly  the  mus- 
cle bundles,  have  been  pushed  apart,  the  interstices  created  are  filled 
out  by  a  serous  exudate  (oedematous  infiltration),  and  almost  the 
whole  thickness  of  the  sac  is  undermined  by  the  phagocytic  action  of 
the  syncytium.  What  becomes  of  the  ovum  after  rupture,  has  been 
indicated  already  in  discussing  intraligamentous  and  abdominal  preg- 
nancies. 

Tubal  abortion  is  brought  about  by  either  of  two  causes  or  by  a 
combination  of  the  two.  These  causes  are  hemorrhages  and  contrac- 
tions of  the  tube  wall.  The  latter  will,  however,  be  impossible  when 
the  muscular  coat  of  the  tube  has  been  weakened  very  much  by  rare- 
faction and  oedematous  infiltration. 

The  embryo  in  ectopic  gestation,  as  a  rule,  no  matter  what  occurs, 
is  arrested  in  its  development  and  dies.  Even  if  it  goes  on  to  full 
development,  it  must  perish  unless  relieved  artificially  from  its  ectopic 
position.  But  interstitial  tubal  pregnancy,  when  leading  to  tubo- 
uterine  gestation,  may  terminate  in  a  natural  manner  without  artificial 
aid.  If  the  development  of  the  embryo  in  ectopic  pregnancy  is  arrested 
early  in  consequence  of  rupture  or  abortion,  and  if  the  foetus  gets  into 
the  general  peritoneal  cavity,  it  is  speedily  absorbed,  so  that  after  a 
few  days  there  is  no  trace  left  of  it.  Older  embryos,  arrested  in  devel- 
opment, become  the  subject  of  either  mummification  and  litliopcedion 
formation  or  of  maceration.  The  latter  process  usually  takes  place  if 
the  embryo  Has  been  deprived  of  its  protecting  foetal  membranes. 
Maceration  brings  with  it  the  danger  of  septic  infection  or  putrid 
changes.  The  process  of  calcification  of  an  ectopic  ovum  may  assume 
one  of  three  forms.  If  only  the  foetal  membranes  become  infiltrated  with 
lime  salts,  we  speak  of  a  lithokelyphos;  if  the  foetal  membranes  and 
the  superficial  tissues  of  the  foetus  are  incrusted,  we  speak  of  litho- 
TcelypJiopcedion,  while  litliopcedion  proper  signifies  the  condition  when 
the  embryo  alone  presents  as  a  calcareous  mass.  Lithopfedion 
formation  is  not  infrequently  found  after  the  death  of  a  fully  de- 
veloped foetus  has  been  brought  about  by  spurious  labour.  A  litho- 
pjcdion  may  often  remain  for  years  in  the  abdominal  cavity  v^ithout 
giving  rise  to  trouble,  yet  may  ultimately  bring  trouble  about  after 
having  been  harmless  for  a  long  period  of  time.  Tubal  gestation  may 
be  a  twin  pregnancy,  and  cases  of  bilateral  tubal  pregnancy  have  been 
observed.  Repeated  tubal  pregnancies  have  likewise  been  recorded. 
Ilenrotin  (he.  oil.,  p.  380)  saw  an  abdominal  pregnancy  brought  about 
by  an  attempt  of  the  patient  to  produce  an  abortion  in  the  seventh  week 
of  normal   uterine  gestation.     A   sharp  instrument  inserted  into  the 


656  A    TEXT-BOOK   OF   GYNECOLOGY 

uterine  cavity  perforated  the  fundus.  The  ovum  escaped  into  the 
general  peritoneal  cavity  and  kept  on  developing,  the  placenta  spread- 
ing from  the  uterine  cavity  to  the  peritoneal  coat  of  the  womb.  This 
pregnancy  had  to  be  terminated  by  an  operation  during  the  fifth  month 
of  gestation. 

The  uterus  in  ectopic  pregnancy  undergoes  hypertrophy.  The 
latter  is  of  course  mostly  confined  to  the  muscular  coat.  The  uterine 
mucous  membrane  is  changed  into  a  decidvia.  That  this  is  the  case 
was  maintained  years  ago  by  Langhans  and  others.  There  have  been 
those,  however,  again  and  again,  who  assert  that  there  is  no  uterine 
decidua  formed  in  tubal  pregnancy.  Herzog,  who  has  studied  uterine 
scrapings  from  a  number  of  cases  of  tubal  pregnancy,  finds  that  a 
decidua  is  formed.  It  is  not  materially  different  from  the  decidua  vera 
as  formed  in  normal  uterine  jDregnancy.  This  decidua  is  frequently 
shed  at  the  time  of  rupture,  abortion,  or  when  the  embryo  dies  from 
any  cause.  This  accounts  for  the  fact  that  a  number  of  observers, 
making  an  examination  at  an  improper  time,  have  not  found  any 
uterine  decidua  and  have  been  misled  into  the  belief  that  none  is 
formed  in  tubal  pregnancy.  The  uterus  as  a  whole  in  ectopic  preg- 
nancy enlarges  to  the  size  of  a  womb  in  the  third  or  fourth  month 
of  normal  pregnancy.  Beyond  this  stage  it  rarely,  if  ever,  hyper- 
trophies; it  then  either  remains  stationary  or  frequently  even  be- 
comes gradually  smaller.  This  is  always  the  case  as  soon  as  the 
embryo  is  arrested  in  its  development  by  rupture,  abortion,  or 
otherwise. 

The  Histology  of  Tubal  Pregnancy. — The  study  of  the  microscopic 
anatomy  of  tubal  pregnancy  is  by  no  means  an  easy  matter.  By  far 
the  greater  number  of  cases  are  only  operated  upon  after  primary  or 
even  secondary  hemorrhages  have  occurred,  and  the  material  obtained 
under  such  conditions  is  often  eminently  unsuited  to  draw  trustworthy, 
valuable  conclusions  from,  as  to  histogenetic  details.  Even  in  cases 
operated  on  before  any  rupture  has  taken  place,  there  may  have  oc- 
curred intervillous  hemorrhages,  which  will  greatly  disturb  the  normal 
relation  of  the  component  parts  of  the  placenta.  Of  a  large  number 
of  cases  of  ectopic  gestation,  only  a  comparatively  small  percentage  can 
be  relied  upon  to  furnish  valuable  material  for  microscopic  examina- 
tion, and  even  this  can  only  be  properlj  interpreted  by  one  who  has 
been  a  faithful,  patient  student  of  the  histogenesis  of  the  normal 
uterine  placenta,  a  subject  itself  offering  considerable  difficulties. 
These,  of  course,  become  greatly  augmented  when  we  deal  with  an 
ectopic  implantation  of  the  ovum.  The  following  short  description 
of  the  histology  of  tubal  pregnancy,  Herzog  bases  upon  the  microscopic 
examination  of  over  30  cases.  In  a  book  of  this  kind  it  Avould,  of 
course,  be  very  much  out  of  place  to  discuss  in  detail  all  the  contested 
points,  of  which  there  are  quite  a  number,  in  regard  to  the  histogenesis 
of  the  normal  placenta  as  well  as  of  that  of  tubal  pregnancy.  It  will 
be  necessary  to  be  brief  and  somewhat  dogmatic. 


ECTOPIC   PREGNANCY 


657 


Fig.  282. — "  A  dilFereiitiatiori  into  a  decidua  compac- 
ta  and  a  decidua  spongiosa." — Heezog  (page  658). 


From  observations  recently  made  by  Van  Heukelom  and  Peters 
upon  very  young  hmnan  ova  obtained  in  situ  in  the  uterus,  it  appears 
that  the  human  ovum,  like  that  of  other  mammals,  is  surrounded,  soon 
after  fecundation,  by  a  layer 
of  solid  ectoblast,  called 
"  trophoblast."  In  this,  many 
nuclei  but  no  individual  cell 
boundaries  are  distinguish- 
able. The  trophoblast,  as 
it  appears,  has  phagocytic 
properties  and  enables  the 
ovum  to  corrode  its  way  into 
the  uterine  mucosa,  which  at 
this  early  time  has  already  as- 
sumed the  character  of  the 
decidua.  If  this  is  the  normal 
modus  operandi,  and  the  ob- 
servations cited  very  strongly 
suggest  that  it  is  so,  it  is  easy 
to  understand  how  an  im- 
pregnated ovum  may  implant 
itself  into  the  tubal  mucosa. 

The  mode  of  implantation  would  be  exactly  the  same  as  in  the  uterus, 
because  it  depends  chiefly,  if  not  exclusively,  upon  structures  and  prop- 
erties of  the  fertilized  ovum  itself.    From  the  trophoblast  are  later  on 

developed  the  villi  with  their 
two  ectodermal  layers,  viz., 
the  inner  cell  layer  of  Lang- 
hans  and  the  outer,  nucle- 
ated Plasmodium,  the  syn- 
cytium. The  very  first 
stages  of  placental  formation 
have  never  been  observed  in 
ectopic  pregnancy. 

If  we  turn  to  what  has 
been  observed,  the  following 
outlines  may  be  given:  The 
early     placenta     foetalis     in 
tubal    pregnancy    is    in    no 
way  different  from  the  same 
structure  in  normal  uterine 
development    of    the    ovum. 
The    villi    possess    a    meso- 
dermal core  with  foetal  blood 
vessels    and    a   double    ecto- 
dermal   lining,    the    cell    layer    of    Langhans    and    the    syncytium. 
The  placenta  materna  presents  a  decidua  serotina  not  so  well  de- 
43 


Fig.  283. — "The  pseudo-gland  spaces  .  .  .  have  been 
formed  by  the  deeper  recesses  between  the  origi- 
nal plicae." — Heezog  (page  658). 


658  A   TEXT-BOOK   OF   GYNECOLOGY 

velojjed  as  in  normal  uterine  pregnancy,  but  sliowing  large  typical 
decidual  cells  and  a  division  into  a  decidua  compacta  and  a  decidua 
spongiosa  (Fig.  382).  The  open  spaces  in  the  spongiosa  are  fre- 
quently lined  by  high  columnar  epithelium.  This  may  also,  how- 
ever, be  more  or  less  flattened,  or  it  may  have  degenerated  entirely 
and  be  found  to  have  dropped  off  into  the  lumen  of  the  pseudo-gland 
spaces.  The  latter  have  been  formed  by  the  deeper  recesses  between  the 
original  plicse  of  the  tubal  mucous  membrane  (Fig.  283).  The  changes 
which  the  plica?  undergo  in  tubal  pregnancy  consist  in  a  club-shaped 
thickening  and  a  transformation  of  the  fine  connective  tissue  spindle 
cells  into  elements  of  the  character  of  decidual  cells.  The  plical  blood 
vessels  become  enormously  dilated  to  form  the  tubo-placental  blood  si- 
nuses. Neighbouring  plica  become  confluent  at  their  higher  parts,  and 
this  gives  rise  to  the  formation  of  the  ui^per  .compact  layer  of  the  de- 
cidua, while  the  deeper  recesses  between  the  plica?  give  rise,  as  already 
stated,  to  the  pseudo-gland  spaces,  forming  in  this  manner  the  lower 
spongy  layer  of  the  decidua.  The  formation  of  the  decidua  vera  is  simi- 
lar to  that  of  the  serotina,  but  the  vera  as  a  rule  does  not  extend  very 
much  beyond  the  place  of  insertion  of  the  ovum.  The  formation  of  a 
decidua  reflexa,  or  capsularis,  in  tubal  pregnancy  has  been  denied.  Her- 
zog  has,  however,  reported  an  instance  that  is  beyond  doubt.  If  the 
above-described  mode  of  implantation  of  the  human  ovum  is  correct,  as 
it  most  probably  is,  then  the  formation  of  a  capsularis,  or  decidua  re- 
flexa, in  tubal  pregnancy  is  very  easily  explained.  Herzog  has  previously 
insisted  upon  the  fact  that  a  decidua  reflexa  must  always  be  formed  in 
tubal  pregnancy.  He  says  in  connection  with  this  subject  {The  Practice 
of  Ohstetrics  by  American  Authors,  1899,  p.  362):  "At  an  early  period 
in  uterine  gestation  an  intervillous  space  filled  with  maternal  blood, 
bounded  on  the  outside  throughout  most  of  its  extent  by  the  decidua 
reflexa,  surrounds  the  whole  chorion.  In  tubal  pregnancy,  therefore, 
there  must  also  always  be  formed  a  decidua  reflexa,  because  an  intervil- 
lous space  capable  of  maintaining  the  maternal  blood  can  be  formed 
only  by  a  decidua  reflexa,  unless  we  assume  that  the  tube  very  easily  be- 
comes obliterated  on  both  sides  of  the  ovum.  Since  we  have  no  proof 
at  all  of  such  a  very  improbable  occurrence,  a  decidua  reflexa  becomes 
an  absolute  necessity  for  the  establishment  of  the  intervillous  space." 
This  was  written  before  the  observations  of  Peters  on  a  very  young 
human  ovum  were  published.  These  have  since  furnished  some  much- 
desired  elucidation  about  the  establishment  of  the  intervillous  space 
and  the  formation  of  the  decidua  reflexa.  This  brings  us  to  the  ques- 
tion of  the  intervillous  space  in  ectopic  pregnancy.  How  a  recent 
writer  (Kuehne,  Beitrdge  zur  Anatomic  der  Tuharschwangerschaft,  Mar- 
burg, 1899)  can  state  with  all  seriousness  that  an  intervillous  space 
with  maternal  blood  is  never  formed  in  tubal  pregnancy,  is  a  matter 
difficult  to  understand.  If  we  consider  that  tubal  pregnancies  have 
gone  to  full  term  and  have  been  terminated  by  the  delivery  of  a  living 
child,  we  must  insist  from  merely  theoretical  reasoning  upon  the  estab- 


ECTOPIC  PREaNANCY 


659 


Fig.  284. — "  An  intervillous  space." — Herzog. 


lishment  of  an  intervillous  space  with  maternal  blood.    But  aside  from 
any  theoretical  reasoning,  we  find  favourable  cases  enough  which  per- 
mit us  to  recognise  an  inter- 
villous space  (Fig.  284). 

The  changes  going  on  in 
the  muscularis  of  the  tube 
consist  in  a  hypertrophy  of 
the  muscle  cells.  As  in  the 
uterus,  their  number  does 
not  seem  to  be  increased,  but 
each  individual  fibre  be- 
comes enlarged.  The  num- 
ber of  muscle  cells  normally 
found  in  the  tube  is,  of 
course,  very  small  compared 
with  the  number  found  in 
the  muscularis  of  the  uterus. 
The  gestation  sac  formed  in 
tubal  pregnancy  consequent- 
ly must  soon  be  very  inade- 
quate in  thickness,  and  oedematous  infiltration  and  inflammatory 
changes  must  take  place  (Fig.  285).  This,  of  course,  as  is  seen  in  every 
single  case,  always  comes  to  pass.  Microscopic  examination  of  the 
gestation  sac  shows  that  the  bundles  of  muscle  fibres  become  separated 

by  interstices.  These  are 
often  filled  out  with  fibrous 
connective  tissue,  but  fre- 
quently we  only  find  an 
oedematous  or  serous  mate- 
rial between  the  muscle  bun- 
dles. The  whole  tube  wall, 
including  the  decidua,  is  in- 
filtrated with  cellular  ele- 
ments of  an  inflammatory 
type,  such  as  polynuclear 
leucocytes  and  lymphocytes; 
plasma  cells  are  likewise 
found.  This  inflammatory 
reaction  is  brought  about  by 
coagulation  necrosis,  in  con- 
sequence of  pressure  and 
pulling  and  smaller  and 
larger  apoplectic  insults 
from  enormously  enlarged  tubal  vessels.  But  all  of  these  changes, 
which  as  a  rule  only  become  pronounced  when  the  ovum  has  reached 
a  certain  size,  do  not  seem,  to  be  sufficient  to  explain  very  early 
ruptures.     It  appears  to  Ilerzog  that  one  of  the  most  important,  if 


Fig.  285. — "  fEdeinatous  infiltration  and  inflamma- 
tory chan^e.s  must  take  place." — Heezog. 


660 


A  TEXT-BOOK  OF  GYNECOLOGY 


not  the  most  important^  factor  in  the  production  of  early  rupture 
in  tubal  pregnancy,  is  furnished  by  the  behaviour  of  the  syncytium 
The  latter  in  tubal  pregnancy  displays  greater  phagocytic  properties 
or  greater  penetrating  powers  than  in  normal  uterine  gestation.  In 
the  latter  we  see  the  syncytium  often  penetrate  deeply  into  the  de- 
cidua.  But  it  appears  that  the  uterine  muscularis  offers  to  the  fur- 
ther progress  of  the  syncytium  an  obstacle  as  a  rule  unsurmountable. 
It  is  different  in  tubal  pregnancy.  Here  there  is  no  strong,  solid, 
dense  muscularis.  We  have  on  the  contrary  a  rarefied,  cedematous 
tissue,  and  in  it  one  can  frequently  see  that  the  syncytium  pene- 
trates through  almost  the  entire  thickness  of  the  gestation  sac.  It 
is  this  circumstance  which  appears  to  Herzog  as  of  the  greatest 
importance  in  bringing  about  the  conditions  which  lead  to  early 
rupture  in  tubal  pregnancy  at  a  time  when  the  pressure  of  an  en- 
larging ovum  can  not  yet  be  held  as  adequately  responsible  for  the 
accident.     The  extensive  penetration  of  the  syncytium,  as  found  in 

specimens  of  tubal  preg- 
nancy, reminds  one  forcibly 
of  the  syncytial  proliferation 
as  found  in  placentoma  ma- 
lignum.  Decidualike  cells 
are  also  found  in  the  outer 
layers  of  the  gestation  sac, 
and  one  occasionally  meets 
decidual  masses  on  the  peri- 
toneal covering  of  the  tube. 
Here  these  decidualike  struc- 
tures are  furnished  by  pro- 
liferating peritoneal  endo- 
thelium. 

Operations  for  ectopic 
pregnancy  furnish  excellent 
material  for  the  study  of  the 
histology  of  the  corpus  lutem 
verum  (Fig.  286).  One  is  surprised  to  find  occasionally  that  the  ovary 
of  the  side  on  which  the  tubal  pregnancy  occurred  does  not  show  a 
corpus  luteum  verum  but  that  the  ovary  of  the  opposite  side  contains 
this  structure.  This  observation,  not  infrequently  made  by  a  number 
of  workers  on  the  subject,  has  given  rise  to  the  probably  correct  notion 
that  tubal  pregnancy  is  occasionally  the  result  of  an  impregnated  ovum 
wandering  from  one  side  to  the  opposite  tube.  Here  the  ovum  becomes 
implanted  before  it  can  reach  the  uterus  and  gives  rise  in  this  manner 
to  an  ectopic  gestation. 

Symptomatology. — The  symptoms  of  ectopic  pregnancy  of  course 
vary  with  its  progress,  according  to  the  integrity  of  the  sac,  and  to 
whether  the  foetus  is  living  or  dead.  In  the  early  period  the  ordi- 
nary signs  of  pregnancy  are  to  be  observed.    Among  these,  cessation  of 


Fig.  286. — "  The  corpus  luteum  verum." — Herzog. 


ECTOPIC  PREGNANCY  QQl 

menstruation,  nausea,  and  changes  in  the  breasts  are  to  be  mentioned, 
though  any  and  all  of  these  symptoms  may  be  absent,  or  modified  by 
individual  peculiarities.  As  a  rule,  however,  menstruation  is  delayed 
or  missed;  and  the  patient  exhibits  sufficient  of  the  classical  symptoms 
of  pregnancy  to  direct  attention  to  the  probability  of  such  a  condition. 
The  recurrence  of  menstruation,  which  is  usually  irregular  and  pro- 
fuse, is  a  part  of  the  early  history  of  this  condition;  and  the  shedding 
of  the  decidua  in  the  form  of  shreddy  discharges,  constitutes  a  valuable 
diagnostic  symptom  of  the  early  period. 

The  objective  symptoms  consist  of  an  enlarged  uterus  with  softened 
cervix  simulating  normal  pregnancy,  and  with  a  soft  and  movable  tu- 
mour upon  one  side  of  the  uterus.  A  microscopic  examination  of  the  ex- 
pelled decidua  will  often  disclose  the  character  of  that  membrane  posi- 
tively and  thereby  facilitate  diagnosis.  Prior  to  the  rupture  of  the 
tube,  the  symptoms  are  obscure  and  uncertain  and  the  physical  signs 
are  for  the  most  part  those  of  normal  pregnancy.  AVhen  rujDture  oc- 
curs (Fig.  387),  which  invariably  happens  by  the  end  of  the  twelfth 
or  fourteenth  week,  the  symptoms  are  marked  and  often  most  alarming. 
The  pain  is  sharp  and  agonizing,  and  is  referred  to  the  pelvis.  There 
is  also  a  bloody  flow  from  the 
uterus  at  this  time.  The  pa- 
tient will  usually  exhibit  the 
symptoms  of  profound  shock 
and  internal  hemorrhage.  It 
is  not  uncommon  for  the  pa- 
tient to  fall  to  the  floor  and 
suft'er  profound  shock,  and, 
in  a  large  proportion  of  cases, 
fatal  collapse  from  pain  and 

hemorrhage  will  supervene  Fig.  287.—"  When  rupture  occurs  ...  the  symp- 
within  a  few  hours.      In  other  toms  are  marked."— McMuetet. 

cases  the  symptoms  will  not  be 

so  severe  and  extreme.  The  rupture  may  be  only  partial  and  the  hemor- 
rhage slight,  when  the  symptoms  will  be  correspondingly  light  and  tran- 
sient. After  a  brief  interval  varying  from  a  few  hours  to  several  days, 
the  rupture  will  extend  with  renewed  pain  and  pronounced  symptoms  of 
intra-abdominal  hemorrhage.  Associated  with  this  condition  will  be  gen- 
eral abdominal  tenderness;  followed  later,  if  left  alone,  by  symptoms  of 
peritonitis.  With  primary  intraperitoneal  rupture  there  is  hemorrhage, 
but  the  detection  of  efl'used  blood  inside  the  peritoneum  is  difficult  and 
uncertain;  hence  in  this  condition  bimanual  examination  will  avail  but 
little  at  first  in  detecting  the  effusion.  Later,  when  the  blood  has  gravi- 
tated and  coagulated,  the  physical  signs  elicited  by  bimanual  examina- 
tions will  show  the  pelvis  to  be  filled  with  a  semisolid  mass. 

When  tubal  abortion  occurs,  the  symptoms  may  be  of  such  limited 
severity  as  to  deceive  the  patient  and  physician  as  to  the  nature  of  the 
illness.    The  ovum  is  detached  from  its  bed  in  the  ampullar  extremity 


662  A  TEXT-BOOK  OF  GYNECOLOGY 

of  the  tube  and,  with  the  accumulated  blood  of  successive  hemorrhages, 
forms  a  mass  to  become  absorbed  or  to  be  walled  off  by  adhesions.  The 
general  symptoms  will  be  those  of  a  tender,  boggy  mass  and  localized 
peritonitis,  readily  confounded  with  other  forms  of  tubal  disease. 
When  rupture  occurs  with  cleavage  of  the  folds  of  the  broad  ligament, 
but  without  rupture  into  the  general  peritoneum,  the  symptoms  are 
very  obscure.  The  pain  is  paroxysmal,  is  prone  to  recur,  and  varies 
as  to  its  severity.  The  symptoms  of  collapse  are  not  so  severe  as  when 
intraperitoneal  rupture  occurs,  due  to  the  limited  hemorrhage — limited 
because  of  the  resistance  of  the  inclosing  layers  of  the  broad  ligament. 
This  is  the  form  of  ectopic  pregnancy  which  permits  continued  vitality 
and  development  of  the  fcetus.  Secondary  rupture  takes  place  later 
into  the  peritoneal  cavity,  and  may  occur  so  soon  after  primary  rupture 
that  they  can  scarcely  be  distinguished.  Few  foetuses  survive  the 
fourth  month,  and  the  symptoms  during  these  months  result  from  the 
ruptures  of  the  investing  tissues,  and  the  hemorrhages  associated  inevi- 
tably with  these  changes.  After  the  fourth  month,  if  the  foetus  sur- 
vives, the  symptoms  are  those  of  intrauterine  pregnancy  with  the  modi- 
fications which  would  reasonably  obtain  under  the  altered  environment 
of  the  growing  foetus. 

Diagnosis. — From  the  above  exposition  of  the  symptoms  of  ectopic 
pregnancy,  diagnosis  will  be  approximately  made  in  most  cases  before 
bimanual  examination  is  utilized.  When  the  history  and  symptoms  are 
considered  in  conjunction  with  careful  bimanual  examination,  the  diag- 
nosis will,  as  a  rule,  be  readily  established.  Diagnosis  during  the  first 
week  and  prior  to  rupture  is  rarely  practicable,  not  only  on  account  of 
the  vague  and  obscure  character  of  the  symptoms,  but  also  from  the 
fact  that  the  symptoms  are  rarely  sufficiently  active  to  impel  the  patient 
to  seek  medical  advice.  Menstruation  is  absent  or  retarded  during  this 
stage,  and  hemorrhage  coming  on  later  marks  the  shedding  of  the  de- 
cidua.  Physical  examination  is  of  doubtful  significance,  as  the  unrup- 
tured tube  may  be  displaced  posteriorly  or  may  recede  from  the  exam- 
ining fingers  as  does  a  cystic  ovary  or  hydrosalpinx.  Under  these  cir- 
cumstances, the  general  symptoms  of  nausea  and  changes  in  the  breasts 
and  uterus  will  afford  those  presumptive  indications  upon  which  a 
tentative  diagnosis  will  be  made.  When  the  primary  intraperitoneal 
rupture  takes  place,  the  symptoms  of  severe  localized  pain,  varying  in 
degree  with  the  extent  of  rupture,  together  with  the  indubitable  signs 
of  intraperitoneal  hemorrhage,  readily  establish  the  diagnosis.  This 
generally  occurs  about  the  seventh  week  and  is  usually  the  first  positive 
symptom  that  impels  the  patient  to  seek  advice.  Ectopic  pregnancy  is 
most  frequently  observed  in  women  with  pre-existing  pelvic  disease, 
which  fact  renders  slight  menstrual  disturbances  of  minor  significance. 
A  vaginal  examination  at  the  time  of  rupture  is  often  negative  on 
account  of  the  presence  of  pain  and  muscular  contraction.  After  the 
paroxysm  of  pain  has  passed,  a  mass  on  one  side  of  the  uterus  will 
be  apparent  to  the  bimanual  touch.    The  diagnosis,  however,  is  deter- 


ECTOPIC  PREGNANCY  663 

mined  more  by  the  distinct  indications  of  hemorrhage  than  by  the  de- 
tection of  a  tumour.  General  abdominal  tenderness  is  usually  present 
with  the  symptoms  of  shock  and  collapse. 

When  the  rupture  is  into  the  fold  of  the  broad  ligament,  the  pain 
is  more  variable  as  to  its  severity  and  is  usually  paroxysmal.  The 
shock  is  correspondingly  less  marked  and  the  volume  of  effused  blood 
is  limited  by  the  resistance  of  the  peritoneal  folds  composing  the  broad 
ligament.  When  the  rupture  occurs  into  the  broad  ligament  very 
early  in  the  period  of  pregnancy,  the  pain  and  hemorrhage  may  be 
very  slight  and  may  pass  unrecognised  as  if  the  condition  was  one  of 
ordinary  menstrual  pain  or  colic.  Such  cases  often  recover  entirely 
without  treatment,  the  ovum,  secundines,  and  effused  blood  being  ab- 
sorbed. When  secondary  rupture  into  the  general  peritoneal  cavity 
occurs  in  this  form  of  tubal  pregnancy,  there  is  a  recurrence  of  pain, 
with  the  symptoms  of  hemorrhage  and  shock  very  similar  in  character 
and  severity  to  primary  intraperitoneal  rupture. 

If  the  ovum  survives  after  secondary  rupture  by  retaining  sufficient 
vascular  attachment  to  the  tubal  mucous  membrane  for  its  support,  an 
altogether  different  and  more  marked  series  of  diagnostic  indications 
makes  its  appearance.  These  advanced  symptoms  are  marked  after  the 
fourth  month  and  are  both  general  and  local.  The  general  diagnostic 
symptoms  are  those  characteristic  of  advanced  pregnancy,  and  consist 
in  absence  of  menstruation,  changes  in  the  breasts,  vulva,  and  uterus, 
abdominal  enlargement,  movements  of  the  foetus,  placental  souffle,  and 
ballottement.  Palpation  of  the  foetus  is  easily  made  on  account  of  the 
thinness  of  the  abdominal  walls.  As  a  means  of  diagnosis,  palpation  is 
an  untrustworthy  resource  in  ectopic  pregnancy,  since  the  same  impres- 
sions may  be  derived  through  the  walls  of  an  attenuated  uterus.  Mc- 
Murtry  has  had  frequent  cases  of  attenuation  of  the  uterus  (American 
Practitioner  and  News)  in  which  repeated  examination  by  several 
skilled  observers  gave  the  impression,  in  the  face  of  a  doubtful  his- 
tory, of  ectopic  pregnancy  nearing  full  term.  Normal  delivery  demon- 
strated the  true  condition  to  be  that  of  attenuated  uterus.  In  such 
cases  the  uterine  walls  are  so  thin  that  the  foetal  head,  body,  and  limbs, 
may  be  followed  by  the  hands,  as  if  subcutaneous.  In  the  diagnosis  of 
all  stages  of  ectopic  pregnancy,  the  fact  that  intrauterine  pregnancy 
may  coexist  should  never  be  forgotten. 

When  the  term  of  pregnancy  is  completed  (Fig.  288)  and  spurious 
labour  supervenes,  the  diagnosis,  if  not  previously  made,  will  be  estab- 
lished without  special  difficulty.  The  pains  are  well  defined,  contrac- 
tile, gradually  increasing  in  duration  and  severity,  recurring  at  inter- 
vals, and  gradually  subsiding.  After  spurious  labour,  and  the  conse- 
quent death  of  the  fcetus,  marked  changes  are  observed  in  the  foetal 
and  maternal  structures.  The  placental  circulation  continues  for  some 
time  after  the  death  of  the  foetus.  The  abdomen  is  usually  decreased 
in  size,  fcjetal  movements  cease,  and  the  uterus  undergoes  involution. 
In  a  certain  proportion  of  cases,  the  gestation  sac  and  foetus  undergo 


664 


A  TEXT-BOOK  OF  GYNECOLOGY 


necrotic  changes  and  break  down  into  a  gangrenous,  suppurative  mass. 
Hectic  fever  and  general  septic  symptoms  of  severe  type  at  once  appear. 
After  a  severe  and  protracted  illness,  pus  may  find  outlets,  single  or 
multiple,  through  the  abdominal  wall,  rectum,  vagina,  or  bladder,  to 

be  followed  by  the  debris  of 
the  macerated  foetus.  In 
some  instances,  the  foetus  un- 
dergoes mummification,  cal- 
cification, or  is  converted 
into  a  lithopsedion,  so  that 
the  septic  symptoms  men- 
tioned may  be  modified  or  be 
altogether  absent,  in  accord- 
ance with  these  varied  meth- 
ods by  which  the  foetus  and 
secundines  are  managed  by 
the  digestive  activity  of  the 
peritoneum. 

Treatment. — In  the  pre- 
antiseptic  era  of  surgery, 
many  methods  of  treatment 
were  devised  to  arrest  the  de- 
velopment of  the  misplaced 
ovum  and  to  promote  its  ab- 
sorption. Among  these  may 
be  mentioned  the  administra- 
tion of  strychnine  to  a  toxic 
degree,  hypodermic  injections 
of  ergot,  and  puncture  of  the 
cyst.  More  recently,  the  in- 
jection of  morjDhine  into  the  sac,  and  later  the  apj)lication  of  electricity, 
have  been  in  vogue  to  destroy  the  foetus  and  to  facilitate  innocuous  ab- 
sorption. All  these  methods  of  treatment  are  now  obsolete,  and  proper 
surgical  treatment  is  the  only  method  deserving  confidence.  In  no 
field  of  surgery  have  the  results  been  more  brilliant  than  in  the  treat- 
ment of  ectopic  pregnancy.  A  certain  proportion  of  the  cases  of  ectopic 
pregnancy  in  which  rupture  occurs  during  the  early  stages,  recover 
without  operation.  Some  present  themselves  to  the  gynecologist  weeks 
or  months  after  rupture,  with  the  symptoms  of  pelvic  inflannnation  of 
tubal  origin.  Abdominal  section  will  reveal  an  old  and  infected  blood 
clot,  the  removal  of  which  will  be  followed  by  prompt  recovery.  These 
cases  were  formerly  classified  under  the  head  of  suppurating  hemato- 
cele (Fig.  289).  While  recovery  may  eventually  take  place  under  ex- 
pectant methods  of  treatment,  the  larger  proportion  will  be  saved  by 
prompt  abdominal  section  and  removal  of  the  affected  tube  and  its  con- 
tents. In  the  following  classes  of  cases,  viz. — 1.  Unruptured  tubal 
pregnancy;  2.  Cases  of  rupture  without  severe  symptoms;   3.  Cases  of 


Fig.  288. — "  When  the  term  ...  is  completed  .  .  . 
the  diagnosis  .  .  .  will  be  established  without 
special  difficulty." — McMurtkt  (page  663). 


ECTOPIC   PREGNANCY 


665 


rupture  with  developing  infection,  Schauta  has  shown  that  the  mor- 
tality of  ectopic  pregnancy,  when  uninterfered  with,  is  over  65  per 
cent,  while  the  mortality  in  cases  treated  by  prompt  surgical  interven- 
tion is  less  than  6  per  cent;  from  which  it  is  apparent  that  the  patient 
is  exposed  to  greater  peril  by  expectant  treatment  than  by  early  resort 
to  surgery.  As  heretofore  stated,  few  cases  of  ectopic  pregnancy  will 
present  themselves  for  treatment  prior  to  the  time  of  rupture,  con- 
sequently it  is  exceptional  that  an  opportunity  is  found  for  the  simple 
and  safe  operation  prac- 
ticable at  this  stage.  The 
operation  consists  of  ab- 
dominal section  and  re- 
moval of  the  involved  tube 
in  a  patient  free  from 
shock  or  hemorrhage,  and 
where  the  condition  is  un- 
complicated by  inflamma- 
tory lesions. 

When  rupture  has  oc- 
curred, esj^ecially  if  with 
extensive  lesions  directly 
into  the  general  perito- 
neum, immediate  opera- 
tion is  a  necessity  to  save 
life.  The  case  is  one  of 
hemorrhage,  and  to  arrest 
the  bleeding  is  as  impera- 
tive here  as  to  secure  the 
severed  ends  of  a  wounded 
blood  vessel  in  other  lo- 
calities. The  operation 
in  these  cases  is  one  of 
emergency,  oftentimes  to 
be  done  immediately  upon 
seeing  the  i)atient  and 
recognising  the  condi- 
tion, with  all  the  haste 
that    is    compatible    with 

due  regard  to  reasonable  aseptic  operative  precautions.  When  the  peri- 
toneum is  incised  through  an  abdominal  incision,  blood  clots  will  present 
themselves  through  the  incision.  These  must  be  rapidly  turned  out, 
the  ruptured  tube  sought  with  the  exploring  fingers,  and  secured  with 
a  clamp.  The  hemorrhage  having  been  arrested  by  this  manoeuvre, 
the  operator  can  deliberately  ligate  tlie  ruptured  tube  at  the  uterine 
cornu,  and  cleanse  the  peritoneum  of  all  fresh  blood  and  clots.  When 
primary  rripturo  has  preceded  operation  for  a  sufficient  time,  old  and 
disintegrated  blood  clots  will  be  found.    Irrigation  with  hot  saline  solu- 


FiG.  289. — >■'■  These  cases  were  formerly  classified  under 
the  head  of  suppurating  hematocele." — McMuetby 
(page  664). 


QQQ  A  TEXT-BOOK  OP   GYNECOLOGY 

tion  will  subserve  a  double  purpose  in  removing  these  clots,  and,  by 
rapid  absorption  through  the  peritoneum,  in  overcoming  the  associated 
shock  and  anaemia.  During  the  progress  of  the  operation  in  these 
cases,  as  well  as  prior  and  subsequently  to  that  procedure,  hypodermic 
medication  and  saline  infusion  should  be  applied  to  maintain  the  circu- 
lation. McMurtry  has  had  the  gratifying  experience  of  witnessing  the 
return  of  the  pulse  at  the  wrist  under  this  treatment,  when  the  patient 
seemed  beyond  surgical  aid  from  the  severity  of  the  hemorrhage.  The 
anaesthetic  should  be  given  barely  to  the  point  necessary  for  permitting 
the  operation  without  pain,  and  should  be  laid  aside  at  the  earliest 
possible  moment  in  order  to  avoid  adding  anything  to  the  profound 
shock  already  existing.  Ether  is  to  be  preferred  in  these  cases  on 
account  of  its  stinuilating  effect.  The  question  of  drainage  must  be 
determined  by  the  indications  of  individual  cases.  Where  irrigation 
has  been  required,  drainage  for  twenty-four  hours  by  means  of  a  glass 
tube  will  usually  prove  advantageous,  and  will  also  give  assurance  as 
to  hemostasis.  When  the  patient  is  placed  in  bed,  dry  heat  should  be 
applied  and  the  foot  of  the  bed  elevated.  When  a  patient  has  passed 
safely  the  immediate  danger  from  rupture,  with  the  pelvis  filled  with 
blood  clots  and  membranes  undergoing  septic  changes  and  suppuration, 
it  may  be  best,  if  she  has  become  feeble  from  sepsis,  to  incise  the  fornix 
vaginte  and  remove  disorganized  clots  and  septic  foci,  thereby  pro- 
viding an  outlet  and  securing  drainage.  In  all  other  conditions,  the 
surgical  requirements  of  ectopic  pregnancy  will  be  best  subserved  by 
abdominal  section  rather  than  by  vaginal  incision. 

The  operative  treatment  in  advanced  ectopic  pregnancy  will  vary 
as  the  foetus  is  living  or  dead,  and  according  to  the  consequent  state  of 
the  placental  circulation.  The  placental  site  varies  in  these  cases, 
and  may  be  on  the  abdominal  wall,  in  the  uterus,  or  spread  out  most 
frequently  over  the  broad  ligament  and  uterus;  in  some  cases  it  is 
also  attached  to  intestinal  and  bladder  surfaces.  After  spurious  labour 
and  the  death  of  the  foetus,  the  placental  circulation  remains  active 
for  some  time.  Hence,  under  these  circumstances  it  is  best  to  defer 
operation  for  several  weeks  in  order  that  the  placental  thrombi  may  be- 
come organized.  Then  the  placenta  can  be  enucleated  without  serious 
danger  from  uncontrollable  haemorrhage.  The  danger  to  life  in  those 
cases  where  the  pregnancy  has  advanced  beyond  the  fifth  month,  and 
especially  in  those  that  have  gone  beyond  full  term,  is  extreme.  The 
difficulty  centres  about  the  removal  of  the  placenta.  When  the  placenta 
is  spread  out  over  the  uterus  and  intestines  and  the  circulation  through 
it  is  active,  a  fatal  hemorrhage  will  usually  follow  any  attempt  at  its  re- 
moval. If  this  condition  is  found  to  exist,  the  cord  is  tied  and  cut 
short  after  removal  of  the  foetus,  and  the  sac  is  stitched  to  the  edges 
of  the  incision  after  packing  it  with  gauze  which  is  allowed  to  protrude 
from  the  lower  angle  of  the  incision.  The  danger  here,  too,  is  great; 
for  the  large  mass  is  readily  infected,  and  secondary  hemorrhage  will 
often  ensue  as  the  placenta  breaks  down.     When  the  foetus  is  alive 


ECTOPIC  PREGNANCY 


667 


and  viable,  operation  should  be  done  without  waiting  for  the  comple- 
tion of  the  full  term  of  pregnancy  and  spurious  labour.  In  opening 
the  abdomen,  the  sac  should  be  avoided  carefully  by  diverting  the  line 


h'ui.  290.—".  .  .  A  patient  who  had  t^ono  two  inonths  beyond  term, -maceration  of  the  foetus 
having  conitnenced." — McMubtky  (page  668). 

of  incision.  When  tbe  sac  is  opened,  the  child  is  extracted  and  handed 
to  an  assistant.  If  tbe  plactrnta  is  favourably  situated,  it  may  be 
rapidly  enucleated  and  the  hemorrhage  controlled  by  firm  gauze  pack- 


668 


A  TEXT-BOOK  OP   GYNECOLOGY 


ing.     Otherwise,  it  may  be  best  to  leave  the  placenta  as  already  de- 
scribed. 

When  the  foetus  has  been  dead  for  several  weeks,  the  dangers  of 
operation  are  much  lessened.  In  these  cases  it  will  often  be  practicable 
to  remove  the  placenta  at  once  without  severe  hemorrhage.  When 
the  foetus  has  been  long  dead  and  has  undergone  mummification,  adi- 
pocere  change,  or  calcification,  the  operative  procedure  for  its  removal 


Fig.  201. 


The  child  was  removed  bv  abdominal  section." — McMurtet. 


will  present  no  additional  difficulties,  and  can  be  conducted  in  accord- 
ance with  the  principle  already  set  forth  in  this  chapter.  Eeed  operated 
on  a  patient  at  the  Cincinnati  Hospital  who  had  gone  two  months  be- 
yond term,  maceration  of  the  foetus  having  commenced  (Fig.  290).  The 
child  was  removed  by  abdominal  section  (Fig.  291)  and  the  sac  sutured 
to  the  margins  of  the  wound  and  packed  with  gauze,  as  the  slightest 
traction  on  the  placenta  induced  hgemorrhage.  The  placenta  was  sub- 
sequently removed,  and  the  patient  made  a  complete  recovery. 


CHAPTEE    XLIII 

NEOPLASMS   OF   THE   BROAD   LIGAMENT 

The  broad  ligament — Varieties  of  neoplasms — Cysts  (parovarian),  origin,  causes, 
symptoms,  complications,  diagnosis,  treatment — Hydrocele  of  the  round  liga- 
ment— Fibroma,  myoma,  and  lipoma;  symptoms,  diagnosis,  treatment — Der- 
moids— Solid  tumours  of  the  round  ligament — Pelvic  varicocele — Aneurismal 
varix  and  phleboliths — Malignant  neoplasms :  Carcinoma ;  sarcoma. 

The  broad  ligaments  consist  of  folds  of  peritoneum,  extending 
from  the  uterus  to  the  bony  wall  upon  either  side  of  the  pelvis.  On 
the  upper  margin  of  each  of  these  peritoneal  folds,  and  extending 
lengthwise  with  it,  is  the  Fallopian  tube,  the  fold  beneath  it  being  fre- 
quently designated  the  mesosalpinx.  Attached  to  the  posterior  fold 
of  the  broad  ligament,  near  its  outer  extremity,  is  the  ovary.  There 
are  various  structures  contained  within  and  beneath  the  folds  of  the 
broad  ligament.     It  is  necessary  in  this  connection  to  consider  only 

(a)  the  round  ligament,  which  extends  from  the  uterus  to  the  inguinal 
ring,  and  over  which  there  drops  a  sort  of  duplication  of  the  peri- 
toneum, usually  designated  the  anterior  fold  of  the  broad  ligament; 

(b)  the  parovarium,  or  the  rudimentary  survivor  of  the  Wolffian 
body;  (c)  the  blood  vessels;  (d)  the  lymphatics;  and  (e)  unstriped 
muscular  fibres.  Each  of  these  several  structures  may  present  patho- 
logic changes  demanding  consideration. 

Neoplasms  developing  within  the  broad  ligament  may  originate 
from  any  of  the  structures  therein  contained.  They  may  be  consid- 
ered under  the  two  classes  of  (a)  benign,  and  (b)  malignant. 

Benign  enlargements,  some  of  which  are  not,  strictly  speaking,  of 
neoplastic  character,  but  which,  for  convenience,  are  grouped  together 
in  this  chapter,  are : 

1.  Cysts  arising  from  the  inner  tubules  of  the  parovarium. 

2.  Fibromata  arising  from  the  fibrous  connective  tissue. 

3.  Myomata  arising  from  the  unstriped  muscular  fibres. 

4.  Fibromyomata  arising  from  the  two  preceding. 

5.  Lipomata  arising  from  the  areolar  tissue. 

6.  Dermoids  arising  from  the  connective  tissue. 

7.  Varicocele  arising  from  the  dilated  veins. 

8.  Aneurismal  varix  arising  from  the  increased  number  and  en- 
largement of  blood  vessels. 

660 


670  ■       ^  TEXT-BOOK  OF   GYKECOLOGY 

9.  Phleboliths  arising  from  the  calcareous  infiltration  of  thrombi. 

10.  Hydrocele  arising  from  the  round  ligament. 
Malignant  Neoplasms: 

1.  Carcinomata  /  -,-,  n         i         •. 

„    <-i  ±        r  are  generally  secondary  deposits. 

2.  Sarcomata      j  o  ^  j       r 

Cysts  developing  in  the  broad  ligament  may  arise  from  (a)  the 
epoophoron  (parovarium),  (h)  the  paroophoron,  (c)  the  round  liga- 
ment (hydrocele).  It  is  important  as  a  preliminary  step  in  this  con- 
nection to  consider  more  in  detail  these  various  structiires — particu- 
larly the  two  former. 

Notwithstanding  that  M.  Sanger,  W.  Fischel  and  Werth  (Archiv 
fiir  Gyndkologie,  Bd.  xv,  xvi)  wrote  in  1880  extensively,  clearly,  and 
correctl}^,  upon  the  tumours  of  the  broad  ligament  and  of  the  struc- 
tures lying  between  its  folds,  Doran  {Tumours  of  the  Ovary  and  Broad 
Ligament,  1885)  expressed  regret  that  the  gynecologists  manifested  so 
little  interest  in  the  parovarium.  Since  then,  however,  most  of  the 
writers  on  gynecology,  and  the  text-books  on  this  subject,  speak  more 
or  less  extensively  of  this  organ  and  its  relation  to  certain  pathologic 
conditions.  While,  clinically,  the  diseases  of  the  parovarium  and  the 
mesosalpinx  can  not,  or  should  not,  be  considered  separate  or  distinct 
from  those  of  the  ovary,  they  are,  nevertheless,  peculiar  to  organs 
that  are  as  different  from  the  ovary  as  is  the  Fallopian  tube;  and 
just  as  the  tubes,  and  the  affections  characteristic  of  them,  are  dealt 
with  by  themselves,  so  should  the  diseases  of  the  parovarium  and  its 
peritoneal  coverings  be  treated  distinctively  and  form  a  chapter  of 
their  own. 

Parovarium  is  the  term  first  used  by  Kobelt.  Waldeyer  called  it 
epooplioron,  in  contradistinction  to  the  paroophoron  (which  lies  closer 
to  the  uterus  and  represents  the  vestiges  of  the  corpus  Geraldes  of  the 
male,  the  parepididymis).  The  organ  was  formerly,  and  still  is,  quite 
generally  known  also  as  the  corpus  Eosenmiiller  because  Eosenmiiller 
gave  the  first  description  of  it.  The  mesosalpinx  is  merely  a  part  of  the 
hroad  ligament.    The  two  terms  should  not  be  used  synonymously. 

Briefly  defined,  the  parovarium  is  that  portion  of  the  female  inter- 
nal genitalia  which  represents  the  atrophic  or  rudimentary  remnant  of 
that  part  of  the  Wolffian  body  that  would  have  become  the  epididymis 
in  the  male. 

Anatomy  (Embryology). — The  parovarium  (Fig.  207)  resides  be- 
tween the  two  folds  of  the  broad  ligament,  and  consists  of  a  number 
of  small,  "  closed  "  tubules  running  transversely  in  a  fan-shaped  ar- 
rangement from  the  ovary  toward  the  Fallopian  tube.  These  tubules 
can  be  easily  detected  by  the  unaided  eye,  if  the  normal  meso- 
salpinx is  spread  out  and  held  up  against  the  light  (Quain).  The 
number  of  tubules  varies,  as  a  rule,  from  10  to  15,  though  there  may 
be  only  half  a  dozen,  or  as  many  as  25  or  30  (H.  C.  Coe).  It  is  said 
that  they  have  no  openings ;  that  they  measure  from  a  little  less  than 
0.5  millimetre  to  1  millimetre  in  diameter;  <that  their  walls  are  0.05 


NEOPLASMS  OF   THE   BROAD  LIGAMENT  Q'Jl 

millimetre  in  thickness,  and  consist  of  an  external  annular  membrane, 
and  an  internal  membrane  of  longitudinal  fibres  (Olshausen),  lined 
with  cuboidal  or  low  cylindrical,  and  sometimes  ciliated,  epithelium; 
and  that  they  are  surrounded  by  several  layers  of  spindle  cells,  appar- 
ently nonstriped  muscular  fibres  (H.  A.  Kelly).  The  longest  and 
largest  of  these  tubules,  which  is  the  remnant  of  the  Wolffian  duct, 
runs  parallel  to  the  Fallopian  tube  along  the  base  of  the  fan  formed 
by  the  rest,  and  then  extends  to  the  side  of  the  uterus  and  becomes 
lost  in  the  vaginal  wall.  According  to  Olshausen,  the  scanty  con- 
tents of  these  tubes  coagulate  on  the  addition  of  acetic  acid.  In  some 
of  the  lower  animals,  the  sow  for  instance,  the  Wolffian  duct  persists 
and  is  known  as  the  duct  of  Gartner.  Occasionally,  traces  of  this 
duct  may  be  seen  in  the  human  female  upon  cross  section  of  the 
cervix  or  body  of  the  uterus.  Those  of  the  vertical  tubules  termi- 
nating near  the  outer  margin  of  the  broad  ligament  are,  by  some  au- 
thors, called  Kobelt's  tubes,  and  it  is  at  their  extremities  that,  very 
often,  small  transparent  cysts  develop,  the  so-called  hydatids  of 
Morgagni. 

The  origin  of  cysts  developing  in  the  broad  ligament  is,  principally, 
from  the  epoophoron  (parovarium).  Occasionally,  though  rarely, 
cysts  may  arise  from  the  paroophoron,  which  lies  close  to  the  uterus. 
When  small,  we  can  distinguish  between  them  only  by  their  location, 
the  former  occupying  the  outer  and  upper,  the  latter  the  inner  and 
lower,  portion  of  the  broad  ligament;  when  large,  whether  peduncu- 
lated and  extending  into  the  peritoneal  cavity  or  subserous,  their 
origin  can  not  be  positively  determined. 

The  parovarian  cystoma  (Fischel,  Archiv  filr  Gyndl-ologie,  Bd.  xv, 
pp.  21-i,  215)  is  the  result  of  a  cystic  degeneration  of  that  part  of 
the  parovarium  which  not  only  extends  into  the  hilum  of  the  ovary, 
but  is  found  where  Pfliiger's  loops  begin  to  have  granulosa-epithe- 
lium,  and  that  is  within  the  cortical  layer  of  the  ovary  itself.  The 
ovarian  tissue,  during  the  development  of  these  tumours,  either  atro- 
phies or  participates  in  the  formation  of  the  same.  These  growths 
have  the  same  physical  characteristics  as  those  that  form  from  the 
epoophoron  and  paroophoron  respectively,  because  they  are  in  reality 
of  parovarian  origin.  They,  too,  remain  intraligamentary ;  but  fre- 
quently become  pedunculated  and  differ  from  the  rest  only  in  contain- 
ing ovarian  tissue,  which,  however,  can  not  always  be  found. 

History. — Up  to  1865,  little  or  nothing  was  known  of  broad-liga- 
ment cysts.  It  is  through  the  observations  and  reports  of  cases  by 
ProchowTiik,  Schroder,  Olshausen,  Spiegelberg,  Gusserow,  and  others, 
that  we  know  something  definite  concerning  these  neoplasms.  But  to 
Wilhelm,  Fischel  and  Olshausen  (1880)  belongs  the  credit  of  first  de- 
scribing minutely,  macroscopically  and  microscopically,  their  structure 
and  relations,  which,  as  will  be  seen,  are  of  no  little  importance. 

The  frequeiicy  of  th(;ir  occurrence  has  never  been  rightly  estimated. 
Formerly,  they  were  considered  quite  rare.     It  is  now  well  known  that 


672  ^        A  TEXT-BOOK  OF   GYNECOLOGY 

they  are  mucli  more  frequent  than  is  ordinarily  supposed.  A^Tiile  they 
are  met  with  less  often  than  ovarian  cysts,  it  must  not  be  forgotten 
that  many  a  cyst  has  been  diagnosticated  as  belonging  to  the  ovary, 
which,  in  truth,  was  parovarian  in  its  origin. 

Cysts  of  the  broad  ligament  may  develop  at  any  time  of  life,  but 
more  especially  after  the  period  of  puberty.  Olshausen's  youngest 
patient  was  fifteen,  Kelly's  oldest,  seventy-three  years  of  age.  As  a 
rule,  they  are  monocysts,  and  vary  in  size  from  1  centimetre  to  40 
centimetres  in  diameter.  The  small  cysts  connected  with,  or  spring- 
ing from,  Kobelt's  tubes  usually  remain  small,  and  do  not  give  rise 
to  any  symptoms.  Both  broad  ligaments  may  be  affected  with  one  or 
several  cysts  at  the  same  time;  or  one  cyst  may  so  develop  as  to  oc- 
cupy both  ligaments  in  course  of  time. 

Every  parovarian  cyst  is,  necessarily,  intraligamentary.  In  a  cer- 
tain sense  they  remain  so;  notwithstanding  that,  in  one  case,  they 
may  grow  into  the  peritoneal  cavity  and  become  more  or  less  pedun- 
culated, and  that,  in  the  other,  the  direction  of  growth  is  toward  the 
pelvic  floor  and  retroperitoneal  space.  In  the  latter  case,  the  tumour 
spreads  the  leaves  of  the  ligament  or  ligaments  apart  and  becomes,  to 
a  great  extent  if  not  entirely,  subserous  in  its  location.  Again,  the 
tumour  may  dissect  up  the  parietal  peritoneum  anteriorly  and  poste- 
riorl}',  or  both.  Their  conduct  in  this  respect  is  like  that  of  the  solid 
tumours  of  the  broad  ligament  already  described.  In  consequence  of 
the  varying  distribution  of  the  parovarian  cysts  and  cystomata,  they 
vary  in  shape  and  give  rise  to  different  symptoms  at  a  certain  period 
of  their  existence.  Those  cysts  which  develop  in  the  direction  of  the 
abdominal  cavity  will  have  more  or  less  of  a  pedicle  (when  the  base 
of  the  ligament  is  not  taken  up,  a  pedicle  may  be  often  formed  by 
traction  upon  the  tumour  during  the  operation),  will  be  perfectly  oval 
in  shape,  and  covered  with  peritoneum  in  every  part.  Those  cysts 
that  grow  downwardly,  separating  the  two  layers  of  the  broad  liga- 
ment, become  to  a  great  extent  irregular  in  outline,  are  covered  by 
peritoneum  in  part  only,  and,  of  course,  have  no  pedicle. 

Parovarian  cysts  are,  then,  either  entirely  or  in  part,  covered  with 
peritoneum  derived  from  the  broad  ligament.  The  outer  surface  of 
the  cyst  or  cystoma  is,  therefore,  smooth,  and  immediately  beneath 
it  can  be  seen  the  blood  vessels  running  in  every  direction.  The  tube 
and  its  fimbriated  extremity  are  very  much  stretched,  and  extend  over 
the  upper  and  posterior  surface  of  the  tumour  to  which  they  are  loose- 
ly, sometimes  firmly,  adherent  (Fig.  392).  The  fimbrige,  especially 
the  fimbria  ovarica,  are  spread  open  and  very  much  elongated.  The 
tube,  as  a  rule,  continues  patulous  and  unchanged  in  its  structure. 
The  ovary,  often  perfectly  normal,  may  be  found  suspended  from,  or 
flatly  attached  to,  the  lower  and  posterior  surface  of  the  growth. 
When  the  ovary  can  not  be  found,  it  may  be  atrophied  and  lost  in,  or 
become  part  and  parcel  of,  the  tumour  itself.  The  latter  event  occurs, 
according  to  Fischel,  in  the  ovarian  cystomata  of  parovarian  origin. 


NEOPLASMS  OF  THE   BROAD  LIGAMENT 


673 


The  cyst  wall  is  made  up  of  peritoneum,  glandular,  muscular 
(smooth),  and  connective  tissues.  Its  inner  surface  is  lined  with  cil- 
iated epithelium  (Fig.  393),  either  alone,  or  in  connection  with  the 


FiQ.  292. — "  The  tube  and  its  fimbriated  extremity  are  very  much  stretched,  and  extend  over 
the  upper  and  posterior  surface  of  the  tumour." — Zinke  (page  672j. 

cylindrical  variety.  The  thickness  of  the  wall  varies,  usually  from 
0.3  to  3.5  millimetres,  although,  at  times,  it  may  be  much  thinner  or 
thicker;  but  it  is  nearly  always  uniform  and  seldom  shows  transpar- 
ent patches.  Its  inner  surface  is  corrugated,  and  not  infrequently 
studded  extensively  with  papillary  formations.  The  corrugation 
Fischel  believes  to  be  due  to  the  presence  of  muscular  fibres  in  the 
cyst  wall;  Olshausen  and 
others,  however,  do  not 
agree  with  him.  The 
smooth  muscular  fibres 
are  found  nearer  the 
outer  surface  of  the  wall 
and  run  in  every  possible 
direction;  they  may  be 
absent  in  spots. 

The  glands  found  by 
Fischel,  which  he  states 
are  lined  with  a  low 
cylindrical  epithelium,  can  not  always  be  detected.  Olshausen  be- 
lieves that  both  glands  and  papillary  formation  are  more  generally 
absent  than  present. 

.  The  fluid  contents  of  the  sac,  too,  vary  much  in  colour,  consistence, 
and  specific  gravity.     Tbis  deyKjnds,  mostly  if  not  always,  upon  the 
44 


Fig.  2'J3  (Pfannenstiel). — "Its  inner  surface  is  lined 
with  ciliated  epithelium." — Zinke. 


674  A  TEXT-BOOK  OF   GYNECOLOGY 

age  and  size  of  the  tumour  and  the  amount  of  blood  that,  from  time 
to  time,  may  escape  into  it  in  consequence  of  occasional  rupture  of 
blood  vessels,  the  result  of  torsion  of  the  pedicle,  distention  or  punc- 
ture of  the  cyst  wall,  or  external  injuries.  In  by  far  the  great  ma- 
jority of  the  small  and  medium-sized  tumours,  the  fluid  is  clear  and 
limpid  like  water,  sometimes  of  a  yellowish  tinge,  sometimes  opales- 
cent, and  contains  little  or  no  albumin.  The  specific  gravity  is  exceed- 
ingly low,  1003  to  1004.  Under  these  conditions,  too,  the  cyst  wall 
is  often  flaccid.  When  the  cyst  is  old  and  large,  the  fluid  is  likely  to 
be  thick,  much  darker  in  colour  (greenish  brown  or  black),  and  may 
contain  considerable  albumin  and  have  a  high  specific  gravity,  1022 
as  in  Schatz's  case.  Sometimes  blood  coagula,  old  and  of  recent 
date,  may  be  discharged  from  the  cyst  when  opened.  Spiegelberg  says 
that  the  parovarian  cysts  may  also  contain  "  paralbumin,  granular 
debris,  decolourized  and  shrivelled  red  blood  corpuscles,  scattered  white 
corpuscles,  large  granular  fat  cells,  and  plates  of  cholesterin." 

Causes. — The  causes  of  intraligamentary  cysts  and  parovarian 
cystomata  are  very  obscure.  Indeed,  we  must  admit  that  we  do  not 
know.  The  following  are  merely  of  a  speculative  nature:  Menstrual 
congestion;  hereditary  predisposition;  chlorosis  during  puberty 
(Scanzoni).  Irritation,  as  from  displaced  or  diseased  pelvic  organs 
and  other  sources,  may  be  admitted  as  a  probable  cause.  Olshausen 
states  that  they  are  rare  in  childhood;  that  no  period  of  life  is  ex- 
empt, and  that  they  are  often  associated  with  ovarian  disease  of  the 
same  or  the  opposite  side. 

Symptoms,  Complications,  and  Diagnosis. — These  may  best  be  con- 
sidered under  one  head.  Partly  and  completely  pedunculated  parova- 
rian cysts,  or  cystomata  free  from  all  complications,  may  not  give 
rise  to  any  symptom  whatever,  except  when  they  assume  great  propor- 
tions; and  then  the  symptoms  may  be  limited  to  enlargement  of  the 
abdomen,  dyspnoea,  dulness,  and  distinct  fluctuation  on  percussion. 
It  is  different  when  there  is  no  pedicle  and  cysts  develop,  in  part  or 
entirely  subserously.  Pelvic  discomfort  and  occasional  pains  may  be 
present  early,  and  may  gradually  increase  in  frequency  and  duration 
as  the  tumour  grows  and  dissects  up  the  pelvic  and  parietal  perito- 
neum, and  displaces  the  viscera  concerned.  Advice  is  sought  early  and 
examination  usually  permitted.  Inspection  of  the  abdomen  may  reveal 
some  enlargement;  percussion,  some  dulness  in  the  lower  part  of  the 
abdomen;  and  bimanual  examination,  a  fluctuating  sv>^elling  with  up- 
ward, downward,  anterior,  posterior,  or  lateral,  displacement  of  the 
uterus  and  some  of  its  appendages.  Here,  too,  there  will  be  noticed  a 
steady  augmentation  of  the  symptoms.  The  bladder  will  become  dis- 
turbed in  its  position  and  this  may  cause  frequent,  painful  micturi- 
tion or  even  incontinence  of  urine.  The  rectum  may  be  affected  in 
the  same  way.  The  symptoms,  then,  in  all  uncomplicated  cases,  will 
vary  according  to  the  size,  age  and  locality,  of  cysts.  As  they  are  of 
very  slow  growth  and  sometimes  stationary,  other  conditions  may  give 


NEOPLASMS  OP   THE   BROAD  LIGAMENT  675 

rise  to  complications,  as,  for  instance,  pregnancy,  rupture  of  the  cyst, 
torsion  of  the  pedicle,  diseases  of  the  uterus  and  its  appendages,  etc. 
The  physician  may  be  consulted  for  any  one  of  these  or  for  several  of 
them,  and  may  discover  the  presence  of  a  parovarian  tumour  by 
accident  rather  than  otherwise,  either  by  his  examination,  or  while 
operating  in  the  abdominal  cavity  for  other  diseases  or  injuries.  It  is 
evident,  therefore,  that  the  diagnosis  is  not  always  easy,  and  that 
errors  may  be  made;  but  let  it  be  remembered  that  fluctuation  is 
nearly  always  very  distinct  and  superficial,  as  in  ascites,  and  that,  if 
the  cyst  wall  is  flaccid,  the  percussion  note  may  change  slightly  with 
the  change  in  posture  of  the  patient.  If  a  spontaneous  rupture  takes 
place,  there  may  be  no  symptoms.  This,  it  is  said,  may  happen  re- 
peatedly, without  even  a  suspicion  on  the  part  of  the  patient,  and  may 
be  eventually  followed  by  recovery.  Rupture  of  the  cyst,  spontane- 
ously or  accidentally,  is  always  followed  by  diuresis;  often,  it  is  also 
followed  by  pain,  in  the  absence  of  complications ;  and  always  by  pain, 
sometimes  by  shock,  and  occasionally  by  sepsis  and  death,  if  this  acci- 
dent occurs  in  the  presence  of  acute  or  chronic  inflammatory  suppura- 
tive complications.  That  there  are  cases  in  which  a  diagnosis  can  be 
made,  can  not  be  doubted.  When  we  find  a  flaccid  abdominal  tumour, 
with  distinct  fluctuation  and  devoid  of  hard  nodules,  which  is  of  slow 
growth,  accompanied  by  a  hstory  of  the  absence  of  pain,  and,  possibly, 
of  repeated  rupture  without  serious  consequences,  it  seems  safe  to 
conclude  that  we  are  dealing  with  a  broad-ligament  cyst.  But  it  may  be 
wise  not  to  be  too  positive  even  then.  At  the  present  high  stage  of  devel- 
opment of  abdominal  and  pelvic  surgery,  puncture  of  any  cystic  growth 
for  diagnostitial  purposes  must  be  mentioned  only  to  be  condemned. 

To  distinguish  between  a  papillary  parovarian  cystoma  and  a  mul- 
tilocular  cyst  of  the  ovary,  we  need  only  remember  that  the  former  is 
mostly,  if  not  always,  bilateral;  that  it  is  always  intraligamentary, 
and  that  the  inner  surface  of  the  cyst  is  lined  by  ciliated  epithelium. 

Treatment. — The  treatment  of  parovarian  and  other  cysts  of  the 
broad  ligament  is  very  much  like  that  of  the  solid  tumours  of  this 
structure.  Formerly,  puncture  of  the  cyst  was  earnestly  advised,  and 
is  still  held  out,  by  some,  as  worthy  of  trial  now.  Zinke  can  not  sub- 
scribe to  this  view.  It  may  be  true,  though  he  is  inclined  to  doubt  it, 
that  some  patients  have  been  cured  by  this  means.  He  does  not 
doubt  that  hundreds  of  women  afflicted  with  these  growths  have  each 
been  successfully  tapped  many  times,  and,  in  some  instances,  hun- 
dreds of  times ;  but  he  knows,  also,  from  personal  experience  and  the 
experience  of  others,  that  in  the  great  majority  of  all  the  cases  so 
treated,  nearly  all  were  but  temporarily  relieved  and  eventually  died 
of  exhaustion.  In  some,  adhesions  were  caused  that  subsequently 
complicated  the  extirpation  of  the  growth;  and  in  others,  conditions 
were  established  that  resulted  in  the  death  of  the  patient,  as  the  result 
either  of  carelessness  or  of  errors  in  diagnosis.  There  is  no  class  of 
cases  that,  when  U'cc  U-om  complicntions,  recover  more  promptly  from 


676  A  TEXT-BOOK  OP  GYNECOLOGY 

radical  operative  procedures  when  done  under  strictly  aseptic  precau- 
tions than  these.  The  pedunculated  variety,  especially,  admits  of 
easy  removal  of  even  very  large  tumours  and  through  a  very  small 
incision.  Those  cases  which  develop  within  the  broad  ligament  with- 
out a  pedicle,  are  often  shelled  out  with  ease,  and  not  unfrequently 
a  pedicle  ma}'  be  made  of  a  part  of  the  base  of  the  broad  ligament 
not  taken  up  by  the  cyst,  and  of  a  part  which  is  stripped  from  the  lat- 
ter during  its  enucleation.  In  the  class  of  cases  that  are  entirely  sub- 
serous or  extraperitoneal,  as  in  the  solid  tumours  of  the  broad  liga- 
ment, enucleation  of  the  entire  cyst  may  be  accomplished  and  the 
cavity  left  treated  in  the  same  way  as  recommended  under  Treatment 
of  Solid  Intraligamentary  Tumours. 

Should  the  removal  or  enucleation  of  a  cyst  seem,  for  any  reason, 
impossible,  or,  on  account  of  existing  complications,  inadvisable,  then 
the  plan  of  removing  part  of  the  cyst  and  stitching  the  edge  of  the 
remaining  portion  to  the  abdominal  wound  for  the  purpose  of  packing 
and  drainage,  as  first  advised  by  Spencer  Wells,  and  practised  by  01s- 
hausen,  Winckel,  Sanger  and  others,  may  be  resorted  to,  and  complete 
recover}^  confidently  expected.  Some  of  our  German  confreres,  also, 
state  that,  in  the  absence  of  complications,  the  sewing  of  the  remain- 
ing portion  of  the  sac,  as  just  described,  is  really  unnecessary ;  because 
its  contents  and  what  may  be  subsequently  secreted,  will  be  readily 
absorbed  by  the  peritoneum;  the  sac  eventually  shrivels  up,  atro- 
phies, and  the  patients  recover  perfectly  and  permanently. 

An  important  innovation  in  the  technique  of  operations  for  intra- 
ligamentary cysts,  was  devised  almost  coincidently,  and  with  equal 
originalit}',  by  Hall  of  Cincinnati  and  Hawkins  of  Denver.  The 
method,  which  is  essentially  a  supravaginal  hysterectomy,  is  described 
by  Hall  as  follows: 

"  Open  the  abdominal  cavity  in  the  usual  manner.  Then,  tap  the 
cyst  and  empty  it.  Xext,  ligate  the  ovarian  artery  on  the  tumour  side 
at  the  pelvic  border.  legate  the  ovarian  artery  on  the  opposite  side, 
outside  the  ovary  if  that  organ  is  to  be  removed,  inside  it,  if  it  is 
to  be  left.  Divide  the  peritoneum  crosswise  above  the  top  of  the 
bladder  and  push  the  bladder  down.  Ligate  the  uterine  artery  on  the 
healthy  side.  Cut  across  the  cervix,  and  clamp  or  ligate  the  uterine 
artery  on  the  tumour  side.  The  blood  supply  is  then  cut  off  and  the 
patient  has  not  lost  a  drachm  of  blood.  The  capsule  of  the  tumour 
can  now  be  divided  at  a  suitable  point  behind  and  in  front,  and  the 
tumour  can  be  enucleated  from  below  upward  with  much  greater  ease 
than  from  above  downward,  and  with  corresponding  safety  to  the 
ureter,  the  rectum,  and  the  iliac  vessels.  Close  the  peritoneum  over 
the  pelvic  floor  with  running  sutures  of  catgut.  Every  part  of  the  field 
of  operation  is  in  view  of  the  operator."  The  drawing  (Fig.  294)  from 
a  specimen  of  Hall's,  shows  the  extent  of  the  operation. 

This  operation,  which  certainly  offers  the  maximum  of  safety  to 
the  patient,  is  one  that  necessarily  involves  the  loss  of  the  reproductive 


NEOPLASMS   OF   THE   BROAD  LIGAMENT 


677 


Fig.  294. — "  A  specimen  of  Hall's  "  (intraligamentary 
cyst). — Eeed  (page  676). 


power.  This  may  be  a  matter  of  serious  moment  in  certain  cases,  and 
should  not,  therefore,  be  done,  except  after  the  menopause,  or  when 
fecundity  has  been  destroyed  by  disease;  or  as  a  matter  of  emergency, 
and  even  then  as  a  matter  of  policy  it  is  better  to  have  the  consent 
of  the  patient.  Intraligamentary  cysts  may  be  removed  by  enucleation 
without  damage  or  conse- 
quence to  the  reproduc- 
tive apparatus,  although 
this  is  manifestly  more 
hazardous  to  the  patient 
than  is  the  Hall-Hawkins 
operation. 

Hydrocele  of  the 
round  ligament  may  de- 
velop precisely  as  does 
hydrocele  of  the  sper- 
matic cord  in  the  male. 
The  pathology  is  essen- 
tially the  same  in  the  two 
conditions,  with  the  ex- 
ception that,  in  women, 
the  dropsical  accumula- 
tion is  much  more  re- 
stricted, being  as  a  rule 

limited  to  the  canal  of  Xuck;  the  sac  may  present  at  the  inguinal 
ring,  or  even  protrude  beyond  it,  as  a  fluctuating  tumour,  suggestive 
of  a  hernia  with  a  fusion.  It  is  not  ordinarily  a  painful  affec- 
tion, although  it  may  occasion  enough  disturbance  to  attract  atten- 
tion to  it,  when  the  exact  character  of  the  difficulty  may  be  ascertained. 
Treatment  may  consist  of  (a)  puncture,  followed  by  different  varieties 
of  injections;  (6)  free  incision  of  the  sac,  followed  by  sterilized  tam- 
ponade; or,  (c)  extirpation  of  the  sac.  The  two  former  methods  are 
painful,  tedious,  and  uncertain — ^the  last-named,  alone,  being  entitled 
to  the  designation  of  radical.  Yolbrecht  operates  upon  hydrocele  of 
the  round  ligament,  when  the  sac  is  large  and  located  high  up,  by 
making  a  section  of  the  inguinal  canal  in  its  entire  length.  The  sac 
is  then  isolated  and  cut  away,  a  ligature  being  placed  upon  the  pedicle; 
the  canal  is  then  sutured,  layer  to  layer,  as  in  the  Bacini  operation. 

Fibroma,  Myoma,  and  Lipoma  of  the  Broad  Ligament. — Fibroma 
and  myoma  may  develop  in  the  broad  ligament  as  such  pure  and  simple, 
or  combined  (fihromyoma).  They  are  subject  to  cystic  degeneration 
in  this  as  well  as  in  other  regions  of  the  body  (cystofiiroma  or  cysto- 
myorna).  The  myoma  of  the  broad  ligament  is  the  leiomyoma  of 
Ziegler,  because  it  is  made  up  principally  of  newly  developed,  un- 
striped  muscular  fibres.  Prior  to  1880,  the  primary  development  of 
these  tumours  in  the  bioad   ligament  was  almost  universally  denied. 

To  M.  Sanger  (Archiv  fiir  nyiinj-ohif/ie,  Bd.  xvi,  1880,  s.  258)  be- 


678  A  TEXT-BOOK   OF   GYNECOLOGY 

longs  the  credit  of  establishing  a  definite  clinical  autonomy  for  this 
variety  of  intraligamentary  neoplasms.  He  states  that  Klob,  in  186-i, 
questioned  the  possibility  of  the  independent  development  of  the 
same;  though  Kivisch,  in  1849,  admitted  the  primary  formation  of 
small  fibroids,  but  when  he  saw  large  ones,  they,  in  his  opinion,  could 
only  arise  from  the  uterus.  Scanzoni  (1875)  was  of  the  same  opinion; 
he  attributed  their  origin  to  small  blood  extravasations.  Even 
Schroder  (1879)  denies  that  fibroma  and  myoma  have  their  genesis 
in  the  broad  ligament,  notwithstanding  that  Virchow  recognised  their 
primary  development  in  this  locality,  and  Schetelig  (Arcliiv  fur  Gynd- 
hologie,  Bd.  i,  s.  459)  had  described  a  large  "  cystomyoma  teleangeiectodes 
cavernosum  of  the  right  broad  ligament,"  which  showed  its  genuine 
developmental  origin  to  be  from  the  unstriped  muscular  fibres  of  the 
same.  Sanger  then  quotes  the  cases  of  Schmidt  {Prager  medicinische 
Wocliensclirift,  1878,  s.  35)  and  Mikulicz  {^Yietm'  medizinisclie  Wochen- 
schrift,  1878,  s.  19-21).  That  of  the  former  was  a  case  of  fibrosarcoma 
weighing  8  kilogrammes  (17.60  pounds);  it  sprang  from  the  right 
broad  ligament,  had  a  long,  tolerably  thick  pedicle,  and  occurred  in 
a  patient  thirty-three  years  old.  The  latter  was  an  oedematous  fibro- 
myoma  weighing  5  kilogrammes  (11  pounds),  and  developed  in  the  left 
broad  ligament  of  a  nullipara  aged  twenty-two  years,  and  single.  The 
latter  tumour  was  of  slow  growth,  was  complicated  with  ascites,  and 
had  a  very  thin  pedicle.    Both  patients  recovered. 

It  is  interesting  to  note  that  even  Professor  Winckel,  so  late  as 
1887,  still  clung  to  the  idea  that  myomata  of  the  broad  ligament  were 
at  first,  probably,  subserous  or  intraparietal,  and  grew  from  the 
uterus  into  the  broad  ligament;  he  admits,  however,  that  primary 
gro^vi;hs  have  been  observed.  There  is  no  reference  at  all  to  intra- 
ligamentary fibroma  and  myoma  in  Mann's  American  System  of  Gyne- 
cology, 1888.  The  same  must  be  said  of  Thomas  and  Munde's  Prac- 
tical Treatise  on  the  Diseases  of  Women,  1891.  Senn,  in  his  book  on  the 
Pathology  and  Surgical  Treatment  of  Tumours,  1895,  p.  511,  speaks  of 
the  primary  formation  of  myofibromata  within  the  broad  ligament,  but 
still  maintains  that  "  not  infrequently  "  they  originate  from  the  uterus. 
Kelly  {Operative  Gynecology,  1898)  no  longer  discusses  the  question,  and 
describes  and  illustrates  a  variety  of  cases.  A  beautiful  representation 
of  a  cystic  myoma  can  be  found  on  p.  394,  vol.  ii,  of  his  work. 
Baldy  {American  Text-hook  of  Gynecology)  devotes  not  quite  one  page 
to  the  consideration  of  intraligamentary  fibroids,  and  calls  them  "  ex- 
ceedingly puzzling."  Zinke  states  that  Edwin  Eicketts  presented  3 
cases  of  intraligamentary  fibroids  to  the  Academy  of  Medicine  of  Cin- 
cinnati, Ohio,  weighing  severally  16,  8,  and  65  pounds.  They  were  re- 
moved from  patients  aged  forty-four,  fifty-one,  and  forty-eight  years 
respectively.     The  last  died;   the  two  former  recovered. 

Zinke  also  maintains  that  at  this  time  it  is  simply  impossible  to 
estimate  the  frequency  of  these  growths.  They  are  rare;  but  they  do 
occur  sufficiently  often  to  demand  the  full  attention  of  every  gyne- 


NEOPLASMS   OF  THE   BROAD  LIGAMENT  679 

cologist  and  abdominal  surgeon.     According  to  Rosenwasser  (Annals 
of  Gynecology  and  Paidiatry,  vol.  iv,  No.  6,  1891) — 

Olshauseu  found  among  280  ovariotomies  20  intraligamentary 
Wylie  "  "      500  "  6 

Munde  "  "      154  '•  18 

Rosenwasser  "  "        12  "  6  " 

or       "       946  '^  50  "  =  18.85  per  cent. 

Sanger  (1880)  remarks:  "  I  have  the  conviction  that  our  experi- 
ence with  solid  tumours  of  the  broad  ligament  will  be  like  that  with 
parovarian  cysts.  At  one  time  believed  to  be  great  rarities  and  prac- 
tically unimportant,  they  have  been  observed  so  frequently  that  every 
laparotomist  must  take  them  into  account." 

The  only  references  Zinke  can  find  to  lipomata  of  the  broad  liga- 
ment are  contained  in  Pozzi's  Treatise  on  Gynecology,  p.  187;  in  Senn's 
Pathology  and  Treatment  of  Tumours,  p.  407,  which  is  merely  a  quota- 
tion of  the  former;  and  in  Winckel's  Diseases  of  Women,  p.  598.  Pozzi 
saw  one  case  that  had  been  mistaken  for  an  ovarian  cyst.  An  explora- 
tory puncture  was  made,  and  the  patient  died  of  embolus  three  days 
later.  Terrillon  is  cited  by  Pozzi  as  removing  a  lipoma  springing  from 
the  mesentery  and  weighing  60  pounds.  Winckel  quotes  Pernice,  who 
extirpated  one  weighing  30  pounds  from  the  right  broad  ligament; 
his  patient,  aged  sixty-four  years,  recovered.  Winckel  also  gives  credit 
to  Klob  and  Orth  as  having  seen  similar  cases.  After  quoting  Rokitan- 
sky,  who  observed  a  lipoma  the  size  of  a  walnut  on  the  lower  border 
of  the  tube  in  a  woman  aged  forty-seven  years,  Winckel  dismisses  the 
subject  by  saying  that  "  lipomata  have  no  practical  significance  be- 
cause of  their  small  size." 

The  clinical  character,  symptoms  and  diagnosis  of  solid  tumours  of 
the  broad  ligament  are  much  the  same  as  those  produced  by  the  cysto- 
mata  of  this  region.  They  are  of  slow  growth,  not  tender  to  the  touch, 
and  are  with  or  without  pedicle.  When  pedunculated,  as  in  Dr. 
Schmid's  case,  they  extend  freely  into  the  general  peritoneal  cavity 
and  admit  of  comparatively  easy  removal;  when  there  is  no  pedicle, 
the  tumour  develops  subperitoneally,  spreading  the  folds  of  the  broad 
ligament  apart  and  forcing  the  uterus  to  one  or  the  other  side.  Like 
some  of  the  parovarian  cysts,  these  tumours  may  dissect  up  the  parietal 
peritoneum  anteriorly  or  posteriorly  or  both,  and  thus  present  great 
difficulties  during  efforts  at  their  removal.  The  diagnosis  is  by  no 
means  easily  made,  and,  so  far  as  Zinke  is  able  to  determine,  in  the 
great  majority  of  the  cases  observed,  it  is  arrived  at  only  after  the 
abdomen  has  been  opened.  This,  too,  is  his  own  individual  experience 
with  these  cases. 

The  treatment  of  the  solid  but  benign  tumours  of  the  broad  ligament 
may  be  conveniently  divided  into  palliative  and  curative.  Both 
methofls  of  procedure  are  much  the  same  as  those  in  vogue  for  uterine 
fibroma  and  myoma,  and  the  reader  is  referred  for  the  details  of  descrip- 


680  ^  TEXT-BOOK  OF   GYNECOLOGY 

tion  to  the  chapter  on  this  subject  in  this  work.  Suffice  it  to  state  here, 
that  the  use  of  ergot,  hydrastis  canadensis,  and  electricity,  have  been 
well  tried  by  good,  earnest,  well-trained  men.  The  results  are  anything 
but  satisfactory  so  far  as  a  cure  or  decided  relief  is  concerned.  Apostoli, 
Keith,  Engelmann,  and  many  other  able  and  painstaking  investigators 
of  the  value  of  electricity  in  these  cases,  have  been  disappointed  in 
the  results  obtained,  and  it  is  pretty  generally  believed  that  the  so- 
called  "  cures  "  accomplished,  about  2  A  per  cent  of  many  hundreds  of 
cases,  represent  the  possible  percentage  of  errors  in  diagnosis  {American 
Text-booh  of  Gynecology,  p.  401).  Unfortunately,  the  result  obtained 
with  ergot,  hydrastis  canadensis,  and  iodide  of  potassium,  hypoder- 
matically  or  per  os,  is  not  much  better.  Zinke,  for  a  number  of  years, 
has  given  these  remedies  a  faithful  and  extensive  trial,  even  after 
spending  a  month  with  Apostoli  in  Paris  and  many  years  of  association 
as  pupil  and  assistant  to  C.  D.  Palmer,  who  was,  and  to  some  extent 
still  is,  a  firm  believer  in  and  ardent  advocate  of  these  methods  of 
treatment.  If  there  is  any  doubt  as  to  the  value  of  any  of  these 
means  in  the  treatment  of  uterine  fibroma  and  myoma,  it  would  seem 
that  the  outlook  is  not  very  encouraging  with  the  same  measures  in 
the  treatment  of  intraligamentary  fibromyomata.  There  appears  to  be 
no  record  of  the  application  of  the  above  treatment  in  lipomata  of  the 
broad  ligament. 

The  only  true  remedy  is  removal  of  the  tumour  or  tumours  by 
enucleation  through  the  abdomen;  although  Pean,  and  a  few  others 
who  have  followed  his  method  of  morcellement,  have  done  so  success- 
fully, by  accident  rather  than  otherwise,  by  the  vaginal  route. 

According  to  Olshausen  the  credit  of  first  presenting  and  recom- 
mending the  essential  features  of  the  present  mode  of  enucleating  these 
growths  belongs  to  Miner,  of  Boston  (1869).  The  operation  of  enuclea- 
tion is  not  a  very  difficult  one  if  the  tumour  is  not  large,  and  has 
grown  toward  the  abdominal  cavity  rather  than  into  the  pelvis;  but 
when  excessive  in  size,  both  the  abdominal  and  pelvic  cavities  will  be 
occupied  by  the  tumour.  Again  a  tumour  or  tumours  of  but  moderate 
dimensions  may  be  so  situated  in  the  pelvis  as  to  fill  it  out  completely, 
thus  displacing  the  pelvic  viscera  upward  in  every  direction;  in  addi- 
tion to  this,  there  may  be  numerous  adhesions  and  other  complicating 
diseases,  which  will  make  the  operation  very  difficult  and  formidable. 
Martin,  Hegar,  Kaltenbach,  Olshausen,  Kelly,  Baldy,  and  many 
others,  have  clearly  described  how  to  proceed  under  the  various  con- 
ditions that  may  present  themselves.  The  principal  object  to  be  at- 
tained is  to  avoid  hemorrhage  and  injury  to  other  structures  as  much 
as  possible.  The  ureters,  bladder,  and  the  large  blood  vessels  within 
the  pelvis,  are  especially  endangered  when  the  growth  is  very  large 
or  confined  to  the  pelvis,  and  the  adhesions  numerous  and  firm.  Pe- 
dunculated, solid,  intraligamentary  tumours,  are  very  rare.  Their 
removal  is  simple  enough.  The  stitching  up  of  the  cavity  left  by  the 
peritoneal  folds  after  enucleation  of  the  tumour  is  no  longer  prac- 


NEOPLASMS  OF  THE   BROAD  LIGAMENT  ggl 

tised.  Where  the  folds  fall  into  apposition^  there  is  no  need  for  sewing; 
where  they  remain  separate,  experience  has  shown  that  recovery  is  much 
more  prompt  when,  after  arrest  of  hemorrhage,  the  cavity  is  simply 
cleaned  and  the  abdominal  wound  closed  without  drainage.  Martin, 
Hegar,  and  Kaltenbach  recommended  drainage  into  the  vagina.  Greig 
Smith,  Goodell,  and  Skene  were  the  first  to  abandon  it.  At  present, 
drainage  in  these  cases  is,  with  most  operators,  a  thing  of  the  past. 
We  doubt  whether  Senn,  who  recommended  vaginal  drainage  in  his 
book  on  tumours  (1895),  still  practises  what  he  then  taught.  01s- 
hausen  (1886)  does  not  approve  of  supravaginal  hysterectomy  in  all 
these  cases,  as  has  been  advocated  by  Reuss,  Goffe,  Schenk,  Braun, 
Kelly,  Hall,  and  others.  Olshausen  believes  that  this  procedure  simply 
complicates  and  prolongs  the  operation,  and  should  not  be  resorted  to 
unless  there  is  an  absolute  necessity  for  it.  (See  Treatment  of  Par- 
ovarian Cysts.) 

Dermoid  tumours  of  the  broad  ligament  may  develop  from  the 
underlying  connective  tissue.  Quervain  (ArcMv  filr  Minische  CM- 
rurgie,  Bd.  Ivii,  H.  1),  in  mentioning  this  fact,  alludes  to  15  cases  of 
dermoid  tumours  developing  from  the  pelvic  connective  tissue.  The 
symptoms  in  such  cases  are  due  to  pressure.  Dermoids  in  front  of 
the  rectum  may  simulate  tumours  of  the  cul-de-sac,  those  behind  it 
cold  abscesses  or  serous  or  hydatid  cysts.  Exploratory  puncture, 
though  not  free  from  danger,  may  be  necessary  for  diagnosis,  but  when 
that  is  established  it  is  better  to  operate  as  soon  as  possible.  The 
method  of  operation  depends  on  the  situation  of  the  dermoid;  peri- 
neotomy is  indicated  if  the  tumour  extends  downward,  the  juxtasacral 
incision  if  it  is  high  up,  and  either  of  these  methods  may,  if  necessary, 
be  combined  with  the  extraperitoneal  abdominal.  If  discovered  during 
labour,  the  tumour  may  be  incised  and  drained,  but  should  be  extirpated 
as  soon  as  possible  after  delivery. 

Solid  tumours  of  the  round  ligament  are  occasionally  encountered. 
They  are  rarely  very  large,  and  may  develop  either  from  the  outer 
extremity  of  the  ligament,  when  the  neoplasm  becomes  extraperi- 
toneal, or,  more  properly,  properitoneal;  or  they  may  develop  within 
the  peritoneal  cavity,  when  they  may  be  properly  designated  intra- 
pelvic. 

Weber  {Societe  d' Ohstetrique  et  de  gynecologie  de  8t.  Petershourg)  has 
reported  3  interesting  cases  of  tumours  of  the  round  ligament.  In 
one,  the  tumour  extended  from  the  inguinal  canal  into  the  labium 
majus.  The  growth  was  solid  in  character,  containing  a  few  small 
cavities  filled  with  fluid;  and  was  pronounced  to  be  a  lymphangeiectoid 
fibroma.  In  another  of  his  cases,  a  myoma  originating  in  the  round 
ligament  had  developed  within  the  abdominal  wall.  In  his  third  case, 
a  fibromyoma  was  discovered  inside  the  peritoneal  cavity,  in  the  course 
of  an  operation  for  hernia. 

The  treatment  of  these  cases  is  necessarily  by  operation.  In  the 
properitoneal  variety,  the  tumour  is  exposed  by  a  long  vertical  inci- 


682  A  TEXT-BOOK  OF   GYNECOLOGY 

sion,  crossing  obliquely  the  crural  arcli.  Care  is  then  taken  to  search 
for  the  portion  of  the  tumour  which  lies  in  contact  with,  and  occupies, 
the  inguinal  canal.  If  necessary,  the  inguinal  canal  itself  should  be 
opened  by  free  incision,  the  dissection  being  carried  far  enough  upward 
to  enable  the  operator  to  enucleate  the  tumour,  precisely  as  if  it  were  a 
growth  of  the  abdominal  wall.  When  the  tumour  is  intrapelvic,  it  is 
liable  to  be  mistaken  for  one  of  ovarian  origin.  The  operation,  under 
such  circumstances,  is  precisely  like  an  ovariotomy,  with  the  exception 
that  the  pedicle  should  be  differently  treated.  It  is  to  be  remembered 
that,  in  cutting  away  the  tumour,  a  segment  of  the  round  ligament  is 
likewise  being  removed.  This  deprives  the  uterus  of  one  of  its  anterior 
guy  ropes,  a  defect  which,  if  possible,  should  be  remedied  at  the  time. 
This  may  be  accomplished  by  transfixing  the  two  cut  ends  of  the  round 
ligament  by  means  of  a  ligature  and  bringing  them  together,  the  ap- 
proximation being  strengthened  by  a  fold  of  the  peritoneum,  held  in 
position  by  another  transfixing  but  continuous  suture.  When  these 
tumours  are  large,  they  sometimes  cause  backward  displacement  of 
the  uterus,  which  should  be  remedied  at  the  time  of  operation. 

Fibj'omyomatous  tumours  of  the  round  ligament  are  very  rare.  They 
generally  develop  in  the  extraperitoneal  segment.  Delbet  and  Heresco 
{Revue  de  cJiirurgie),  in  16  cases  of  these  tumours,  found  but  4  devel- 
oping from  the  intra-abdominal  portion  of  the  ligament.  Claisse  ac- 
counts for  their  relatively  greater  extraperitoneal  development  on  the 
theory  that  that  segment  of  the  cord  is  more  liable  than  the  intra- 
abdominal portion  to  repeated,  although  probably  slight,  traumatisms. 
They  grow  to  various  sizes.  Kleinwachter  had  a  case  in  which  the 
tumour  developed  2.5  centimetres  from  the  uterus  and  weighed  1,750 
grammes.  Matthews  Duncan  reported  one  the  size  of  a  hen's  egg; 
Winckel,  one  the  size  of  a  bean.  In  Delbet's  case,  the  tumour  weighed 
5  kilogrammes.  In  Segond's  case,  the  growth  in  the  ligament  was 
associated  with  numerous  similar  growths  in  the  uterus  itself.  Like 
the  latter,  they  occur  for  the  most  part  in  women  of  middle  or  ad- 
vanced life,  and  are  as  liable  to  develop  upon  one  side  as  upon  the 
other.  In  their  structural  origin  and  evolution,  they  are  analogous 
to  fibromyomata  of  the  uterus,  although  their  manner  of  growth 
seems  to  be  by  perivascular  inflammatory  proliferation. 

Pelvic  varicocele,  aneurismal  varix,  and  phleboliths,  may  be  con- 
sidered under  one  head.  Varicocele  of  the  broad  ligament  is  probably 
not  as  uncommon  as  is  supposed.  There  are  but  few  operators  of  long 
and  extensive  experience  who  do  not  come,  accidentall}^,  across  cases 
of  this  kind  in  their  abdominal  and  gynecological  work;  yet  we  find 
the  literature  upon  this  subject  exceedingly  meagre.  The  first  case 
reported  in  this  country  was  that  of  Dr.  Dwight,  of  Boston,  in  1877, 
quoted  by  A.  P.  Dudley,  who,  so  far  as  Zinke  is  able  to  determine, 
wrote  first  in  this  country  exhaustively  on  Varicocele  in  the  Female 
and  reported  4  cases  (Neiv  Yortc  Medical  Journal,  1888,  p.  147). 
Winckel  found  dilatation  of  the  utero-ovarian  veins  not  less  than  10 


NEOPLASMS   OF  THE  BROAD  LIGAMENT  683 

times  out  of  300  autopsies.  He  also  found  thrombi.  Both  Klob  and 
Bandl  have  found  phleboliths  (Pozzi).  Dudley  also  quotes  Brandt  as 
having  often  seen  stones,  the  size  of  peas,  in  the  veins  of  the  broad 
ligament.  Rousan  {These  de  Paris,  1892;  Bagot,  Denver  Medical 
Times)  states  that  pelvic  varicocele  is  of  frequent  occurrence.  Ed- 
ward Malins,  of  Birmingham  (American  Journal  of  the  Medical  Sci- 
ences, 1889,  p.  340),  writes  interestingly  upon  Varicose  Veins  of  the 
Broad  Ligaments,  and  reports  2  cases.  To  this,  Zinke  adds  2  cases: 
one,  an  aneurismal  varix  of  the  right,  and  the  other  a  phlebolith  with- 
in the  left,  broad  ligament.  In  the  former  case,  an  abdominal  section 
was  successfully  performed  for  the  relief  of  uterine  hemorrhage  in- 
duced by  varicose  conditions  in  the  right  broad  ligament.  This  condi- 
tion was  in  turn  brought  on  by  previous  labours  and  was  aggravated  by 
a  laterally  flexed  uterus  in  the  fourth  month  of  gestation. 

In  the  second  case  a  bilateral  salpingo-oophorectomy  and  myomec- 
tomy resulted  in  the  discovery  of  a  phlebolith  4.5  centimetres  long,  1 
centimetre  thick  in  the  centre,  and  tapering  off  toward  each  end,  in 
the  left  broad  ligament  quite  close  to  the  uterus. 

The  causes  of  varicocele  and  aneurismal  varix  of  the  broad  liga- 
ment are,  to  say  the  least,  quite  obscure.  Dudley  in  this  country, 
Malins  in  England,  and  Winckel  in  Germany  are  about  the  only 
authors  who  have  essayed  to  ascertain  the  etiological  factors  of  this 
affection.  Dudley  divides  the  causes  into,  (a)  constitutional,  and  (&) 
mechanical.  Malins  into  general  and  local,  which  is  practically  the 
same. 

(a)  Constitutional  or  general:  Arrest  of  involution  of  the  uter- 
ine and  ovarian  vessels,  keeping  up  pelvic  engorgement  long  after  con- 
finement. A  relaxed  condition  of  the  tissues  from  a  low  state  of  gen- 
eral health.  An  unhealthy  condition  of  the  vessel  walls.  An  absence 
of  valves  in  the  veins. 

(&)  Mechanical  or  local:  The  anatomical  relations  of  the  veins 
themselves;  the  spermatic  and  ovarian  vessels  being  of  such  great 
length  that  the  weight  of  such  a  column  of  blood  has  a  tendency  to 
weaken  the  vessels.     Habitual  constipation.     Uterine  displacement. 

As  a  reason  why  the  left  broad  ligament  is  the  more  frequently  af- 
fected, Dudley  states:  The  emptying  of  the  venous  blood  from  the 
left  broad  ligament  into  the  left  renal  vein  is  at  right  angles  to  the 
blood  current  from  the  kidney,  and  it  obstructs  the  free  flow  of  the 
blood  from  the  ligament  into  the  general  circulation. 

Janni  (Congress  of  Italian  Surgeons,  October,  1898)  asserts  that 
varicocele  is  not  due  to  the  retrogressive  changes  of  the  venous  walls, 
conditional  upon  their  expansion;  but,  frequently,  to  neoplasms  of 
the  elastic  connective  tissue  of  the  intiraa,  which  assumes  the  form  of 
an  actual  endophlobitis  in  knots  or  plaques,  and  is  often  accompanied 
by  neoplasms  of  the  connective  tissue  of  the  median  vein.  These  neo- 
plasms have  not  the  compensatory  character  ascribed  to  them  by 
Eckstein  (Cincinnati  Lancet-Clinic,  April  1,  1899). 


684  A   TEXT-BOOK  OF   GYNECOLOGY 

Zinke  believes  the  causes  just  cited  to  be  without  objection;  but 
thinks  that  intra-abdominal  pressure  from  any  cause  should  be  added 
to  the  list,  and  that  for  the  formation  of  an  aneurismal  varix  in 
this  region,  direct  or  indirect  travunatism  is  necessary,  as,  for  in- 
stance, external  violence,  frequent  application  of  the  forceps  during 
labour,  repeated  abortion,  operations  ujDon  the  cervix,  and  diseases 
of  pelvic  organs.  Phleboliths  result  from  calcareous  degeneration  of 
thrombi. 

The  history  and  symptoms  of  these  cases,  as  Dudley  correctly  re- 
marks, are  those  of  varicocele  in  the  male.  The  pain  is  of  a  heavy, 
dull,  aching  character,  most  marked  and  much  increased  when  the 
subject  remains  long  in  the  erect  posture;  and  correspondingly  less- 
ened, and  even  followed  by  almost  complete  relief,  when  she  is  in 
the  recumbent  position  for  a  long  time.  There  may  be  a  history  of 
traumatism,  malaise,  nervousness,  general  indisposition,  and  even  of 
melancholia.  Frequent  and  profuse  menstruation,  or  even  metror- 
rhagia, in  women  past  the  menopause  may  be  observed  (Zinke). 

The  diagnosis  of  varicocele  must  of  necessity  be  very  difficult  and 
uncertain,  if  at  all  possible,  even  in  well-marked  cases.  Varicosities 
and  vein  stones  are,  as  a  rule,  recognised  only  when  the  abdomen  is 
opened  on  account  of  other  pathologic  processes.  The  same  may  be 
said  of  aneurismal  varix  when  not  very  large;  otherwise  it  may  give 
rise,  as  in  Zinke's  case,  not  only  to  a  palpable,  pulsating  tumour,  but 
to  serious  hemorrhages  from  the  uterus,  especially  when  complicated 
with  pregnancy.  Under  certain  favourable  conditions,  however,  a 
diagnosis  does  not  seem  impossible  in  connection  with  the  symptoms 
given.  When  limited  to  the  broad  ligament  and  free  from  thrombi, 
the  knotted  swelling  felt  with  the  patient  in  the  upright  posture,  will 
be  absent  when  the  patient  lies  down,  and  only  a  doughy,  thickened 
condition,  will  present  itself  to  the  finger  in  the  vagina  or  rectum. 
If  thrombi  are  present,  the  knotted  condition  will  continue  to  exist, 
more  or  less.  At  all  events,  we  must  never  be  too  sure  of  our  diag- 
nosis. 

But  little  can  be  said  as  to  the  course  and  treatment  of  these  cases. 
One  or  all  of  the  three  conditions  may  exist  to  some  extent  for  a 
considerable  period,  and,  perhaps,  for  a  lifetime,  and  not  give  rise  to 
any  symptom  whatever;  or  complications  may  be  present  obscuring 
the  varix  entirely.  If  discovered  during  an  operation,  the  operator 
must  determine  as  to  what  should  be  done  for  the  relief  or  cure  of 
the  patient.  Up  to  the  present  time,  the  experience  of  all  writers 
and  operators  is  very  limited.  Zinke  has  occasionally  removed  vari- 
cosities together  with  diseased  ovaries  and  tubes;  and  when,  as  hap- 
pened in  one  of  his  cases,  the  varix  existed  in  the  broad  ligament 
alone  and  uncomplicated,  he  did  not  interfere,  which  he  now  believes 
was  a  mistake.  Nor  did  it  appear  wise  to  him  to  attempt  the  removal 
of  the  aneurismal  varix  mentioned  above,  because  of  the  existing  preg- 
nancy and  the  injury  done  to  the  uterus  by  the  sac  forceps.     It  is. 


NEOPLASMS   OP   THE  BROAD  LIGAMENT 


685 


however,  more  than  likely  that,  should  another  or  similar  case  present 
itself  to  him  in  the  future,  he  would  dispose  of  the  evil  in  the  man- 
ner pursued  by  Dudley,  of  New  York,  who  operated  upon  4  cases.  In 
case  No.  1,  he  was  able  to  remove  the  varix  with  the  ovary  and  tube, 
just  as  Zinke  did  in  his  three  instances.  In  eases  No.  2  and  3,  Dud- 
ley quilted  both  broad  ligaments  close  to  the  pelvic  floor.  All  his 
cases  recovered  promptly,  perfectly,  and  permanently,  and  he  advo- 
cates radical  treatment  as  the  only  means  to  do  good.  Bleeding  by 
leeching  or  puncturing  the  cervix;  the  daily  use  of  irrigation  with  hot 
water;  the  tampon,  a  well-adjusted  Hodge's  pessary,  and  other  local 
applications  as  recommended  by  Malins  before  removal  of  the  vari- 
cocele is  resorted  to,  will  always  remain  palliative,  not  curative  treat- 
ment. It  is  also  doubtful  whether  the  mere  removal  of  the  ovaries 
and  tubes  will  invariably  produce  good  results. 

Eeed  operates  upon  varicocele  of  the  pampiniform  plexus  by  inter- 
rupted ligatures  inserted  at  short  intervals  by  means  of  a  long-han- 
dled,  curved  needle   (Fig.   395),  and  incision  of  the  veins  between 


Fio.  295. — "  Interrupted  ligatures  inserted  at  short  intervals 

curved  needle." 


)y  means  of  a  long-handled 


the  ligatures.  This  operation  is  applicable  only  when  there  exists 
no  indication  for  the  extirpation  of  the  uterine  appendages.  Under 
the  latter  circumstances,  the  hemostatic  ligatures  should  be  made 
carefully  to  embrace  the  veins  as  well  as  the  arteries,  the  veins  being 
divided  between  the  ligatures.  Division  of  the  veins  is  essential  to 
the  permanent  success  of  the  operation,  as  shown  in  Fig.  296,  in  which 
one  section  of  the  ligated  veins  has  not  yet  been  incised. 

The  influence  of  the  varix  in  the  broad  ligament  upon  the  ovary 
manifests  itself,  according  to  the  histological  researches  of  Paul 
Petit,  in  two  distinct  y)hasos ;  one  of  engorgement,  which  renders  the 
ovary  (edematous  and,  later,  hypertrophied;  and  one  of  sclerosis,  ter- 
minating in  atrophy. 


686 


A  TEXT-BOOK  OF   GYNECOLOGY 


Malignant  Neoplasms:  Carcinoma  and  Sarcoma  of  the  Broad  Liga- 
jnent. — When  the  broad  ligament  becomes  the  site  of  malignant  dis- 
ease it  is,  so  far  as  we  now  know,  of  secondary  origin ;  in  other  words, 
it  is  the  result  of  a  primary  affection  of  the  uterus,  vagina,  ovary,  or 
peritoneum.  According  to  Pozzi,  "  Bandl  has  seen  some  cases  where 
they  came  from  the  pelvic  ganglia."  To  what  extent  the  broad  liga- 
ment may  become  involved,  is  best  illustrated  in  a  case  related  by 


Fig. 


'Jti. — "Division  of  tlie  veins  is  essential  to  the  permanent  success  of  the  operation" 

(page  685). 


Howard  A.  Kelly  in  his  work  on  Operative  Gynecology,  vol.  ii,  p.  331, 
wherein  he  says  he  found  it  "  impossible  to  extirpate  the  disease  in 
the  broad  ligaments  and  to  check  the  free  oozing  from  the  diseased 
tissue  which  was  cut ;  in  order,  therefore,  to  control  the  entire  blood 
supply  going  to  the  part,  I  ligated  both  internal  iliac  arteries  at  a 
point  1  centimetre  below  the  bifurcation  of  the  common  iliacs." 
Winckel  refers  to  Chenieux,  Duplay,  Gortier  and  Hages,  who  have 
reported  operations  upon  sarcomata  of  the  broad  ligament. 

An  involvement  of  the  broad  ligament  in  cancerous  diseases  of  the 
uterus  and  ovary  is  not  rare;  it  is  not  so  frequent  when  the  bladder 
or  vagina  is  the  site  of  the  primary  growth.  Zinke  is  of  opinion  that 
when  the  disease  springs  from  the  uterus  and  involves  the  vagina  and 
broad  ligament  to  but  a  limited  extent,  the  total  ablation  of  the  dis- 
eased organs,  glands,  and  tissues,  through  the  abdomen  will,  in  some 
cases,  insure  permanent  relief.  Zinke  has  2  cases  on  record  in  both 
of  which  he  performed  total  hysterectomy  per  vaginam  eight  years  ago. 
Both  patients  are  still  living  and  in  excellent  health.  One  was  fifty 
years  old,  and  the  victim  of  an  epithelioma  starting  in  the  cervix  and 
implicating  by  extension  the  corpus  uteri,  vaginal  roof,  and  both  broad 
ligaments.  The  operation  was  performed  at  the  German  Hospital, 
March  28,  1892.  The  other  patient,  aged  forty-six  years,  had  a  sar- 
coma of  the  body  of  the  uterus  extending  into  both  ligaments  to  a 
marked  degree,  but  not  sufficiently  to   cause  uterine  fixation.     The 


NEOPLASMS  OF   THE  BROAD   LIGAMENT  687 

operation  was  performed  on  February  22,  1892,  at  the  patient's  home. 
Zinke  now  prefers  the  abdominal  route  in  all  cases  showing  involve- 
ment of  the  uterine  ligaments.  Though  both  the  foregoing  cases  were 
attended  by  excellent  results,  he  feels  that  the  operation  can  be  done 
with  much  more  ease  and  thoroughness  by  going  in  from  above. 


CHAPTEE  XLIV 

INFECTIONS   OF   THE   BROAD   LIGAMENT  AND   OF  THE 
PELVIC  PERITONEUM 

Infections  of  the  broad  ligament— Pyogenic — Pelvic  abscess  ;  treatment — Syphi- 
litic— Parasitic — Tuberculous — Tuberculous  peritonitis,  etiology,  morbid  anat- 
omy, miliary,  caseous,  fibroid,  symptoms,  diagnosis,  prognosis,  and  treatment. 

Infections  of  the  broad  ligament  may  result  from  invasion  by 
various  micro-organisms,  which  may  migrate  thither  from  various 
points  of  entrance  into  the  system,  and  through  different  highways  of 
communication.  Thus,  the  streptococci  finding  their  original  point  of 
entrance  in  an  infection  atrium  of  the  parturient  uterus,  reach  the  broad 
ligaments  and  the  structures  contained  therein  through  the  avenue  of 
the  lymphatics.  The  same  may  be  said  of  the  Bacillus  aerogenes  cap- 
sulatus,  the  staphylococci,  and  the  toxine  of  syphilis,  when  the  uterus 
is  the  site  of  the  primary  sore.  On  the  other  hand,  it  is  exceedingly 
probable  that  the  gonococcus,  so  fruitful  of  mischief  upon  the  mucous 
surfaces,  rarely  if  ever  extends  its  ravages  to  the  subperitoneal  struc- 
tures, although  it  is  a  frequent  cause  of  inflammation  originating  in 
the  peritoneal  side  of  the  broad  ligament.  Echinococcous  infection 
probably  travels  through  the  circulation,  or  else  by  direct  invasion  of 
cellular  areas.  It  is  probable  that  the  colon  bacillus  reaches  this  locus 
by  direct  invasion  of  intervening  structures. 

The  pathology  of  infections  of  the  broad  ligament  depends  somewhat 
upon  the  micro-organism  or  other  causative  infectious  element,  and 
upon  its  avenue  of  ingress.  Wlien  the  lymphatic  system  is  the  high- 
way of  invasion,  the  resultant  phenomena  may  be,  in  the  case  of  less 
virulent  bacteria  or  toxines,  nothing  more  than  an  acute  nonsuppura- 
tive lymphangeitis  (pelvic  lymphangeitis);  or,  in  the  presence  of  more 
virulent  elements,  suppuration  may  ensue;  while,  as  the  result  of 
chronic  infection  of  syphilitic  origin,  there  may  result  that  form  of 
hyperplasia  of  the  lymphatics,  known  as  gummata. 

Pyogenic  infections  depend  chiefly  upon  (a)  the  streptococcus, 
(b)  Bacillus  coli  communis,  (c)  the  staphylococcus,  and  (d)  the  Bacillus 
aerogenes  capsulatus.  As  elsewhere  intimated,  gonococci  seldom  play  a 
part  in  the  production  of  suppuration  in  this  locality.  It  is  unnecessary 
in  this  connection  to  attempt  to  distinguish  clinically  between  these 
various  forms  of  infection.  A  conclusion  on  this  point  may  be  reached 
688 


INFECTIONS  OP   TPIE   BROAD  LIGAMENT  QgQ 

by  studying  the  general  features  of  a  given  case,  as,  for  instance,  in 
puerperal  fever;  for,  as  a  rule,  infection  within  the  broad  ligament  is 
only  a  part  of  the  clinical  and  pathologic  picture. 

Pelvic  Abscess. — Suppuration  in  this  locality  may  begin  at  multiple 
foci,  or  it  may  radiate  from  a  common  centre.  It  may  be  so  circum- 
scribed as  to  defy  detection  by  bimanual  examination,  or  it  may  be  so 
extensive  as  to  lift  up  and  separate  the- folds  of  the  broad  ligament  and 
of  the  parietal  peritoneum;  such  an  accumulation  of  pus  constitutes  a 
tumour,  upon  the  surface  of  which  may  be  seen  the  tensely  stretched 
Fallopian  tube  and  the  ovary,  both  uninfected.  These  are  cases  of  true 
pelvic  abscess. 

The  treatment  of  pelvic  abscess  is  by  evacuation  and  drainage.  This 
may  be  accomplished  in  various  ways,  the  method  to  be  selected  de- 
pending somewhat  upon  the  location  of  the  pus  sac.  If  careful  bi- 
manual examination  indicates  that  the  accumulation  of  pus  has  ex- 
tended forward  and  lifted  up  the  anterior  fold  of  the  broad  ligament, 
and  has  thus  resolved  itself  into  an  essentially  properitoneal  abscess,  an 
inguinal  incision  may  be  made.  This  should  be  done  by  making  a 
careful  dissection  down  to  the  upper  margin  of  Poupart's  ligament, 
after  which  the  peritoneum  can  be  lifted  up  and  the  abscess  cavity  be 
thus  reached  without  opening  the  peritoneum.  If  desired,  through-and- 
through  drainage  may  be  practised  by  making  a  counter  opening  in  the 
fornix  of  the  vagina  and  passing  a  tube  through  the  external  opening 
into  and  through  the  vagina.  (See  Fig.  231.)  If  the  accumulation  has 
burrowed  far  down  along  the  vagina,  vaginal  puncture  may  be  prac- 
tised, as  elsewhere  described  (see  Fig.  225),  and  permanent  drainage 
may  be  established,  either  by  the  introduction  of  a  self-retaining  tube, 
or  by  the  use  of  gauze.  (See  Infections  of  the  Fallopian  Tubes.)  The 
operation  formerly  adopted  by  Tait,  of  making  a  median  abdominal 
incision  and  stitching  the  wall  of  the  abscess  to  the  margins  of  the 
abdominal  Avound  and  draining  in  that  way,  may  still  be  an  operation 
of  choice  in  exceptional  cases.  It,  however,  uniformly  results  in  the 
formation  of  peritoneal  adhesions,  which  must  necessarily  be  the  source 
of  subsequent  pain,  and  is,  therefore,  not  to  be  employed  under  ordi- 
nary circumstances.  Zuckerkandl  operated  upon  these  cases  by  placing 
the  patient  upon  the  side  and  making  an  incision  obliquely  on  the 
affected  side  in  the  sacrococcygeal  region.  This  becomes  an  available 
expedient  in  those  cases  in  which  the  suppuration  has  extended  behind 
the  rectum  and  presents  a  fluctuating  point  in  the  postrenal  region.  It 
liappens  occasionally  that  pus  burrows  almost  or  quite  to  the  vulva, 
under  which  circumstances  an  incision  may  be  made  vertically,  a  little 
to  one  side  of  the  vulvoperineal  region  and  about  4  centimetres  long. 
The  dissection  should  be  carried  up  until  the  levator  muscle  is  ex- 
posed, which  should  be  pushed  to  one  side,  when  the  abscess  cavity 
can  be  easily  reached.  This  is  the  procedure  adopted  by  Sanger, 
which  has  been  modified  l)y  Zuckerkandl,  who  makes  a  transverse 
perineal  incision  in  cases  in  uliich  the  purulent  accumulation  occu- 
45 


690  A  TEXT-BOOK  OF   GYNECOLOGY 

pies  both  sides  of  the  vagina.  Eectal  puncture  has  been  practised  by 
different  operators^  but  while  it  is  a  convenient  method  of  reaching 
tlie  pus  cavity  in  certain  of  these  cases,  it  is  always  liable  to  leave 
a  sinus  which  is  difficult  to  control. 

Syphilitic  infection,  manifesting  itself  in  the  structures  beneath  the 
broad  ligaments,  is  necessarily  secondary  to  a  primary  sore  of  the 
uterus,  or  the  upper  portion  of  the  vagina.  If  the  primary  chancre 
is  located  in  the  lower  portion  of  the  vagina,  or  upon  the  vulvar  struc- 
tures, the  superficial  lymphatics  are  the  first  to  be  involved,  the  second- 
ary disturbance  manifesting  itself  in  the  inguinal  glands.  Lymphangei- 
itis  of  syphilitic  origin  may  be  manifested,  although  rarely,  in  the  lymph 
channels  themselves,  or,  as  is  most  generally  the  case,  in  the  lymphatic 
glands  (lymphadenitis).  The  lymphatic  vessels  may  become  acutely  in- 
flamed and  subsequently  indurated,  exhibiting  the  characteristics  of 
tense,  sensitive  cords,  within  the  more  or  less  diffusely  infiltrated  con- 
nective tissue.  Inflammation  of  the  intrapelvic  lymphatics  occurs  after 
the  first  or  second  week  of  an  initial  infection.  Invasion  of  these  glands 
is  associated  with  fever,  and  with  tenderness  and  enlargement  of  the 
glands  themselves.  They  may  reach  the  size  of  a  hazelnut  or  a  walnut, 
and  they  may  or  may  not  become  the  seat  of  suppuration.  As  a  rule, 
however,  the  tenderness  subsides  after  a  few  days,  leaving  the  glands 
enlarged  and  but  slightly  sensitive  to  the  touch.  This  enlargement,  asso- 
ciated with  but  slight  sensitiveness  on  touch,  may  persist  from  a  few 
weeks  to  several  years.  In  the  irritative  stage,  there  are  marked  hyper- 
semia,  increased  flow  of  serum,  and  enlargement  of  cells.  The  enlarged 
follicles  of  the  gland  present  the  appearance  of  grayish- white  dots; 
with  the  recession  of  the  circulatory  engorgement,  there  occurs  con- 
nective-tissue proliferation,  and  newly  proliferated  tissue  elements 
show  a  marked  tendency  to  become  definitely  organized,  a  fact  which 
accounts  for  the  persistence  of  glandular  enlargement  in  these  locali- 
ties. In  some  instances,  however,  cell  proliferation  progresses  to  such 
a  degree  that  the  newly  formed  elements  can  not  be  sustained  by  the 
blood  supply,  and  then  retrogressive  changes  are  inaugurated.  This 
may  take  the  form  of  either  a  cell  necrosis  eventuating  in  what  Virchow 
designated  caseous  metamorphosis,  or  of  suppuration.  In  still  other 
cases  enormous  gummata  the  size  of  a  man's  fist,  may  develop.  These 
may  be  mistaken  for  fibroids  of  the  uterus,  or  other  fibromyomatous 
growtlis  of  intrapelvic  origin.  Eeed  has  seen  two  cases  of  this  kind,  in 
which  the  exact  character  of  the  enlargement  was  demonstrated.  The 
diagnosis  of  S3rphilitic  infections  of  the  broad  ligament  is  based  chiefly 
upon  an  antecedent  syphilitic  history.  The  treatment  is  by  that  course 
of  medication  which  is  conveniently  designated  under  the  title  anti- 
syphilitic.  In  cases  of  large  gummata,  the  latter  may  be  removed,  ac- 
cording to  their  exact  location,  by  either  abdominal  or  vaginal  section. 

Parasitic  infection  of  the  broad  ligaments  is  chiefly  restricted  to 
invasion  by  the  echinococcus.  It  is  well  known  that  the  echinococcous 
disease  may  attack  any  organ  in  the  body,  and  it  seems,  according  to 


INFECTIONS  OF   THE  BROAD  LIGAMENT  691 

W.  A.  Freund,  Wiener,  and  others,  that  the  broad  ligament  constitutes 
no  exception.  It  is  asserted  (Pozzi)  that  the  echinococci  "  travel  about 
in  all  the  cellular  interstices  communicating  with  the  superior  pelvi- 
rectal space,  which  seems  to  be  their  point  of  entrance,  and  may  thus 
reach  the  broad  ligament,  pass  into  the  iliac  fossa,  and  out  of  the 
pelvis  either  below  or  above  the  crural  arch."  Freund  reported  18 
cases  of  echinococcus  within  the  pelvis  to  the  gynecological  section 
of  the  Fifty-first  Meeting  of  German  Naturalists  and  Physicians  at 
Baden,  1880.  In  10  of  the  cases  the  diagnosis  was  proved  by  section, 
and  in  the  rest,  by  puncture  and  operation  respectively.  It  was  Freund, 
too,  who  determined  the  site  of  the  echinococcus  in  the  pelvis,  the  road 
it  travels,  how  it  grows,  its  relations  to  the  intestines,  its  spontaneous 
existence  if  left  to  itself,  how  to  make  the  diagnosis,  and  the  treatment 
to  be  pursued  (ArcJiiv  filr  Gyndkologie,  Bd.  xv,  1880). 

In  addition  to  the  symptoms  of  the  presence  of  a  pelvic  tumour  or 
tumours,  we  shall  have  the  symptoms  characteristic  of  echinococcus;  if 
the  patient's  health  is  good,  as  it  often  is,  vocation,  association  with 
dogs  (especially  shepherd  dogs),  and  country,  will  aid  us  in  our  diag- 
nosis. The  hydatids  often  cause  inflammation  of  the  pelvic  organs  and 
adhesions  between  them.  The  cysts  which  form  vary  considerably  in 
size;  some  may  grow  so  large  as  to  demand  removal  through  the  abdom- 
inal wall.  When  the  inflammation  is  extensive,  the  disease  may  be 
mistaken  for  cancer.  The  cysts  are  filled,  as  a  rule,  with  a  clear  fluid, 
nonalbuminous  in  character,  and  containing  chlorides  and  sometimes 
traces  of  sugar  (Osier).  Suppuration  may  occur,  especially  when  hook- 
lets  are  found;  when  they  are  absent,  it  is  believed  that  the  fluid  is 
sterile  and  the  cyst  becomes  harmless. 

Medical  treatment  of  these  cases  is  not  very  satisfactory.  The 
cysts,  if  they  become  troublesome,  may  be  attacked  through  the  vagina, 
perineum,  juxtasacral  region  or  the  abdominal  wall.  All  will  depend 
upon  the  location  and  size  of  the  cyst.  The  sac  may  be  completely 
enucleated  or  stitched  to  the  wound  and  then  drained.  Freund  (Pozzi) 
says :  "  If  we  have  to  cut  through  the  peritoneum  we  must,  so  soon  as 
we  reach  the  sac  and  before  opening  it,  use  a  tamponade  of  iodoform 
gauze  for  twenty-four  or  forty-eight  hours,  in  order  to  assure  hema- 
temesis,  and  the  formation  of  protective  adhesions;  at  a  second  seance 
we  can  open  the  sac  under  antiseptic  precautions." 

Tuberculous  infection  of  the  broad  ligament  may  be  manifested  in 
either  the  peritoneum  (tuberculous  peritonitis)  or,  in  the  underlying 
lymphatics.  Tuberculous  infection  of  the  pelvic  lymphatics  rarely 
exists  as  an  independent  manifestation  of  the  disease,  but,  on  the  con- 
trary, is  but  a  local  manifestation  of  a  general  involvement  of  the 
lymphatic  system.  Lymph  adenomata  of  tuberculous  origin  rarely 
attain  the  size  of  those  due  to  syphilitic  infection.  They  are  equally 
chronic  in  their  manifestations. 

Tuberculous  infection  of  the  peritoneal  folds  of  the  broad  liga- 
ment probably  never  exists,  except  as  a  part  of  the  general  tuberculous 


692  A  TEXT-BOOK  OP   GYNECOLOGY 

infection  of  the  peritoneum.  In  view  of  the  fact,  however,  that  the 
reverse  proposition  is  equally  true,  there  may  be  no  impropriety  in 
considering  tuberculous  peritonitis  in  this  connection. 

Tuberculous  Peritonitis. — Tuberculosis  of  the  peritoneal  cavity  is 
one  of  the  most  important  conditions  that  the  gynecologist  is  called 
upon  to  treat.  The  disease  is  characterized  by  the  development  of 
minute  miliary  tubercles  over  limited  or  extensive  areas  of  the  peri- 
toneum, by  ascites,  by  tumour  formation,  and  by  the  development  of 
caseous  abscesses. 

Etiology. — The  cause  in  all  cases  is  the  invasion  of  the  peritoneal 
cavity  by  the  tubercle  bacillus.  The  method  of  this  invasion  is  at 
times  difficult  to  determine,  and  certainly  varies  in  different  cases. 
The  infection  may  take  place  from  the  blood  in  a  very  few  cases.  An 
infection  through  the  female  genital  tract  has  been  found  by  Williams  to 
occur  in  from  40  to  50  per  cent  of  the  cases,  a  fact  which  likewise  has 
support  in  the  greater  frequency  of  tuberculous  peritonitis  in  women 
than  in  men  (Sippel).  The  female  genital  organs  seem  to  afford 
an  easy  portal  of  entrance.  Abbe  has  demonstrated  that  &Q>  per  cent 
of  the  cases  are  infected  from  tuberculous  thoracic  lymph  nodes,  and 
16  per  cent  through  the  mesenteric  lymph  nodes.  The  alimentary 
canal,  certainly,  wvaj  be  the  source  of  infection,  since  it  has  been 
well  demonstrated  that  the  tuberculous  sputum  or  fragments  of  tuber- 
culous lung  (as  used  in  animal  experimentation)  may  cause  an  intes- 
tinal or  a  peritoneal  tuberculosis  (Klebs,  Mosler,  Jans). 

A  previously  depressed  state  of  health  does  not  seem  to  be  a 
predisposing  factor,  since  the  majority  of  these  cases  look  well  nour- 
ished in  the  early  stages  of  the  disease,  and  have  previously  been  in 
good  health.  Pregnancy  shows  a  definite  causal  relationship  which 
has  not  been  adequately  noted  (Kelly). 

The  age  of  the  patient  likewise  seems  to  be  a  predisposing  factor, 
since  the  collected  cases  of  Osier  show  that  the  greater  number  occur 
between  the  ages  of  twenty  and  thirty,  and  that  the  two  extremes  of 
age  are  relatively  immune.  In  regard  to  race,  it  has  been  shown  that 
the  negro  is  more  frequently  affected  than  the  white.  Hereditary 
transmission  of  the  disease  has  been  observed  to  be  an  important 
etiological  factor.  Brunn  has  observed  such  transmission  in  55  per 
cent  of  his  cases,  Brehmer  in  40  per  cent,  Desplans  in  71  per  cent, 
and  Fuller  in  60  per  cent.  A  peculiar  feature  of  the  disease  is  the 
uncommon  occurrence  of  grave  tuberculous  lesions  in  other  parts  of 
the  body.  Schroder  states  that  it  is  a  local  phenomenon  in  70.8  per 
cent  of  cases.  The  presence  of  a  tuberculous  peritonitis  would  seem 
to  afford  an  immunity  to  tuberculosis  elsewhere  (Kelly). 

Morbid  Anatomy. — The  lesions  of  tuberculous  peritonitis  show  de- 
cided variation  in  their  manifestation,  and  permit  of  an  indistinct 
division  into  a  miliary,  a  caseous,  and  a  fibroid  variety.  The  mil- 
iary form  may  appear  and  exist  for  a  long  time  without  giving  the 
slightest  symptoms.     On  opening  the  abdomen  for  other  reasons,  the 


INFECTIONS  OP   THE   PELVIC   PERITONEUM 


693 


peritoneum  of  the  pelvis  or  the  entire  peritoneal  cavity  is  found  to  be 
peppered  with  minute  miliary  tubercles.  The  other  appearances  will 
vary  greatly  with  the  acuteness  of  the  attack,  the  formation  of  adhe- 
sions, etc.  In  an  acute  miliary  tuberculosis,  the  peritoneum  is  notice- 
ably congested  and  thickened,  has  lost  its  normal  lustre,  and  shows 
fresh  lymph  on  the  inflamed  surfaces.  The  fluid  in  the  peritoneal 
cavity  is  j^ellow  or  bloody,  and  may  be  encysted  by  adhesions  or  free 
in  the  general  cavity.  The  adhesions  of  the  intestines  to  each  other, 
or  of  the  omentum,  are  not  usually  extensive  because  of  the  tendency 
to  effusion,  and  they  are  usually  frail  and  bleed  easily. 

The  caseous  variety  is  characterized  by  a  much  more  profound 
anatomical  disturbance,  by  tumour  formation,  caseous  abscesses,  and 
severe  interference  with  the  functions  of  the  intestine.  In  the  most 
severe  eases,  the  peritoneum  throughout  is  the  seat  of  a  caseous  tuber- 
culosis, all  structures  are  agglutinated  by  the  tuberculous  pseudo- 
membrane,  and  the  entire  mass  of  intestine  may  form  a  firm  tumour 
which  is  retracted  against  the  spinal  column.  A  variable  number  of 
encysted  accumulations  of  yellowish  caseous  or  purulent  fluid  may  be 
included  in  the  tumour  mass. 

It  is  the  rule,  however,  to  find  the  disease  more  localized  in  the 
region  of  the  pelvis,  the  csecum,  the  omentum  or  the  liver.  Under 
these  conditions,  the  intestines  adhere  lightly  or  firmly  together  and 
may  wall  off  the  exudates  in  a  more  or  less  distinct  sac  which  repre- 
sents the  entire  lesion,  or 
a  general  ascites  may  co- 
exist. Such  a  sac  may  be 
mistaken  for  a  cyst.  This 
error  may  be  avoided  by 
observing  (1)  the  fine 
white  lines  which  mark 
the  point  of  agglutination 
of  the  intestine  by  lymph 
and  run  parallel  to  it,  and 
(2)  a  faint  vermicular  mo- 
tion after  a  sharp  blow 
with  the  finger.  If  such 
collections  become  puru- 
lent, they  may  lead  to  ul- 
ceration and  intervisceral 
or  external  fistulge  or  they 
may  burrow  extensively. 

Wlien  the  disease  is  lo- 
cal ized  in  the  omentum 
(Fig.  297),  this  organ  be- 
comes greatly  thickened,  but  at  the  same  time  puckered  and  rolled 
up  to  form  a  firm,  elongated  tumour  lying  transversely  across  the  upper 
part  of  the  abdomen.     This  tumour  m;vy  subsequently  caseate  and 


Fig.  297. — "When  tlie  disease  is  localized  in  the  omen- 
tuin,  this  organ  becomes  greatly  thickened."  a,  Typ- 
ical round-celled  miliary  tubercles. — Wiiitacre. 


694  '    ^  TEXT-BOOK  OF   GYNECOLOGY 

ulcerate  either  externally  or  into  the  intestine,  but  such  a  termination 
is  extremely  rare. 

Pelvic  tuberculous  peritonitis  is  generally  associated  with  tubal 
tuberculosis  and  in  this  type  of  the  disease  is  generally  represented 
by  cystic  formation  and  extensive  binding  down  of  all  pelvic  struc- 
tures into  one  hard  mass.  The  cyst  may  extend  well  above  the  pubes, 
and  the  entire  pelvis  is  covered  in  by  a  thick,  friable,  grayish,  tuber- 
culous membrane,  which  is  likewise  adherent  to  the  intestine  above. 
The  pelvic  peritoneum  is  certainly  the  most  frequent  seat  of  tubercu- 
lous peritonitis,  and  this  fact  has  been  explained  by  Weigert,  who  has 
demonstrated  that  the  tubercle  bacilli  always  fall  to  the  bottom  of  the 
peritoneal  cavity. 

The  -fibroid  type  of  tuberculous  peritonitis  is  in  reality  a  terminal 
stage  of  the  preceding  varieties,  more  especially  the  first.  The  miliary 
tubercles  are  found  in  a  quiescent  stage  with  few  cellular  elements 
and  very  few  bacilli,  while  old  adhesions  and  tuberculous  masses  have 
almost  entirely  lost  their  tuberculous  nature,  and  have  been  converted 
into  firm  fibrous  tissue. 

Symptoms. — It  will  be  seen  from  a  study  of  the  lesions  of  tuber- 
culous peritonitis  that  the  symptoms  may  be  entirely  absent,  or  may 
possess  all  the  severity  of  an  extensive  inflammation  of  the  perito- 
neum, and  be  associated  with  those  of  intestinal  obstruction. 

Certain  indefinite  prodromata,  such  as  loss  of  appetite,  loss  of 
flesh,  digestive  disturbance,  or  an  afternoon  fever,  may  be  present,  but 
many  cases  begin  as  a  sudden  attack  of  acute  peritonitis  with  a  tem- 
perature as  high  as  103°  F.,  acute  abdominal  pain,  tenderness,  and 
ascites.  These  symptoms  subside  after  a  few  days  and  the  patient 
continues  with  a  persistent  digestive  disturbance,  indefinite  pains,  an 
afternoon  rise  of  temperature  and  some  tenderness.  The  most  con- 
stant symptom  of  the  slower  form  of  onset  is  pain  referred  to  the 
lower  abdomen  and  pelvic  organs,  and  associated  with  menstrual  dis- 
turbance. This  pain  varies  all  the  way  from  a  continuous  ache  to  a 
most  intense  sufi'ering  that  confines  the  patient  to  bed  (Kelly).  It  is 
described  as  a  bearing-down  pain,  as  shooting  pains,  or  by  the  negro 
as  a  "  misery."  The  pain  is  usually  associated  with  tenderness  over 
the  lower  abdomen. 

Swelling  of  the  abdomen  and  a  sense  of  "  bloating,"  are  also  fairly 
constant  features,  dependent  at  first  almost  entirely  upon  tympanites, 
but,  later,  ascites  adds  to  the  swelling.  This  is  usually  associated 
with  loss  of  appetite,  dyspeptic  symptoms  and  constipation. 

Fever  is  a  marked  symptom  in  the  acute  cases  and  fairly  constant 
as  an  afternoon  rise  in  the  more  chronic  forms.  In  the  latter  it 
reaches  99°  to  100°  F.  and  the  patient  complains  of  having  "  malaria  " 
or  "  chills  and  fever." 

Pain  in  urination  is  given  by  Kelly  as  the  most  characteristic  of 
all  the  symptoms. 

Berggriin  and  Katz  have  found  that  an  abundance  of  fat  in  the 


INFECTIONS  OF   THE   PELVIC   PERITONEUM  695 

stools  of  infants  is  a  valuable  diagnostic  point.  They  state  that,  while 
the  bile  is  fully  secreted  and  acts  normally  to  prevent  putrefaction, 
the  vi^ork  of  fat  digestion  is  imperfectly  done. 

A  striking  peculiarity  of  the  condition  is  the  frequent  occurrence 
of  an  abdominal  tumour.  These  tumours  are  omental,  the  result  of 
sacculated  collections  of  fluid,  are  made  up  of  adherent  masses  of 
intestine  that  have  become  thickened  and  retracted,  or  they  are  formed 
hy  enlarged  mesenteric  glands,  especially  in  children.  They  give  the 
most  confusing  physical  signs  that  are  ever  encountered  in  abdominal 
surgery,  yet  their  very  anomalous  nature  has  come  to  be  looked  upon 
as  one  of  the  diagnostic  features  of  peritoneal  tuberculosis.  An  appar- 
ently solid  tumour  will  give  tympanitic  resonance,  the  confines  and 
the  relations  of  the  tumour  will  often  change  between  two  examina- 
tions, tympanitic  resonance  will  persist  in  the  flanks  in  the  presence 
of  a  considerable  effusion  because  of  the  encysted  condition  of  the 
fluid,  and,  finally,  such  tumours  of  the  uterine  appendages  or  in  the 
region  of  the  caecum  may  simulate  those  of  pyogenic  origin. 

Diagnosis. — The  diagnosis  of  this  condition  presents  many  difficul- 
ties, since  the  signs  that  are  characteristic  of  tuberculosis  in  other 
parts  of  the  body  fail  us  here,  and  it  is  a  well-established  fact  that 
many  cases  of  tuberculous  peritonitis  are  not  diagnosticated  before 
operation.  Nevertheless,  experience  has  taught  us  that  a  diagnosis 
may  usually  be  made  with  certainty  (a)  when  the  abdominal  condition 
is  associated  with  extensive  pulmonary  disease;  (h)  when  tubercle 
bacilli  are  found  in  the  uterine  secretions  or  curettings,  and  (c)  when 
an  anomalous  mass  of  slow  formation  is  found  in  the  pelvis  and  is 
associated  with  an  ill-defined  fluctuating  tumour  of  the  lower  abdo- 
men that  changes  its  relations  from  time  to  time. 

Bulius  has  called  attention  to  the  diagnostic  value  of  tuberculous 
nodules  in  the  pelvic  peritoneum.  These  vary  in  size  from  that  of  a  mil- 
let seed  to  that  of  a  bean,  and  may  often  be  distinctly  felt  on  the  broad 
ligament,  the  Fallopian  tube,  the  lateral  wall  of  the  pelvis  or  on  the  pos- 
terior surface  of  the  uterus  when  this  organ  is  pulled  down  by  a  vol- 
sella  and  examined  per  tectum,.  The  sensation  is  that  of  a  grater. 
The  other  conditions  in  which  such  nodules  may  be  encountered  are 
metastatic  carcinoma,  papillary  cystoma  of  the  ovary,  and  the  small 
blisters  of  certain  forms  of  peritonitis.  Edebohls  has  placed  positive 
diagnostic  value  on  a  plaquelike  thickening  of  the  peritoneum.  The 
exclusion  of  abortion  or  gonorrhoea  in  the  presence  of  a  lateral  mass 
will  make  a  diagnosis  of  tuberculosis  probable  (Morris),  but  it  must 
be  remembered  that  abortion  sometimes  acts  as  a  predisposing  factor 
in  tuberculous  peritonitis.  The  simultaneous  occurrence  of  pleurisy 
with  eff'usioii,  especially  when  this  fluid  is  bloody,  is  a  very  important 
diagnostic  sign.  A  careful  personal  and  family  history  of  the  case 
should  never  be  omitted  since  heredity,  the  history  of  previous  attacks 
of  peritonitis,  the  history  of  "chills  and  fever,"  a  gradual  increase  in 
the  swelling,  a  more  or  less  constant  pain  increased  in  walking,  an 


(596  A  TEXT-BOOK  OF  GYNECOLOGY 

uncertain  percussion  note,  and  loss  of  flesh,  are  among  the  most  im- 
portant clinical  diagnostic  points. 

Finally,  the  diagnosis  has  been  made  absolutely  certain,  according 
to  some  authorities,  by  the  use  of  tuberculin.  If  no  reaction  takes 
place,  the  tuberculous  character  of  the  peritonitis  is  excluded. 

It  must  be  remembered  that  the  tubercle  bacilli  are  rarely  found 
in  the  ascitic  fluid.  But  they  may  be  found  in  the  uterine  or  vaginal 
secretions,  or  the  ascitic  fluid  may  be  injected  into  the  peritoneal  cav- 
ity of  guinea  pigs. 

The  acute  cases  may  be  distinguished  from  typhoid  fever  by  a 
previous  history  of  abdominal  pain,  the  absence  of  rose  spots,  the 
absence  of  diarrhoea  and  continuous  fever,  a  distinct  induration  in 
the  region  of  the  caecum,  and  the  absence  of  the  Widal  reaction. 

Osier  states  that  of  96  eases,  30  were  diagnosticated  as  ovarian  dis- 
ease. In  the  diagnosis  between  tuberculous  peritonitis  and  ovarian 
cyst,  we  are  guided  by  the  history  of  antecedent  disease  of  the  append- 
ages, the  rapid  development  of  an  effusion,  the  ill-defined  nature  of 
the  fluid  tumour,  a  coincident  pleurisy,  the  bacteriological  examina- 
tion of  the  uterine  secretions,  and  by  a  most  accurate  bimanual  ex- 
amination made  per  rectum  when  the  uterus  is  drawn  down. 

Prognosis. — The  age  of  the  patient,  the  advanced  state  of  the  dis- 
ease, and  the  character  of  the  operative  treatment,  will  all  determine 
the  prognosis  in  tuberculous  peritonitis.  The  cases  that  do  well  are 
those  in  patients  of  middle  age  who  have  a  considerable  effusion  of 
fluid  either  free  or  sacculated;  while  the  dry  forms  and  those  cases 
with  extensive  adhesions  of  the  intestines  are  likely  to  do  badly. 

Treatment. — Osier  has  justly  stated  that  a  great  many  cases  of 
tuberculous  peritonitis  recover  spontaneously,  but  it  must  be  remem- 
bered that  errors  of  diagnosis  form  a  constant  factor  in  such  cases, 
and  that  a  diagnosis  often  can  not  be  made  without  an  abdominal  sec- 
tion. Furthermore,  the  nontuberculous  type  of  peritonitis  described 
by  Gusserow,  and  also  by  Henoch,  as  "  peritonitis  nodosa,"  which  is 
identical  in  appearance  with  miliary  tuberculosis  of  the  peritoneum, 
must  form  a  constant  source  of  error  in  medical  cases. 

The  treatment  of  tuberculous  peritonitis  is  invariably  by  laparot- 
omy, and  no  case  should  be  abandoned  as  hopeless  unless  actually 
dying  or  in  such  feeble  condition  that  the  operation  itself  would  be 
fatal.  Simple  incision  and  immediate  closure  of  the  wound  without 
touching  a  single  viscus,  or  the  evacuation  of  the  fluid,  has  resulted 
in  a  cure  of  the  condition,  but  the  indications  of  the  individual  case 
must  be  met  and  certain  principles  adhered  to  in  the  performance  of 
these  operations. 

The  oj)eration  should  have  for  its  object  the  removal,  if  possible,  of 
the  focus  of  the  disease,  the  removal  of  serous  or  purulent  exudate,  and 
the  release  of  dangerous  or  painful  adhesions. 

The  length  of  the  incision  will  vary  with  the  amount  of  manipula- 
tion that  is  necessary  within  the  abdominal  cavity.     The  uterine  ap- 


INFECTIONS   OF   TPIE   PELVIC   PERITONEUM  697 

pendages  should  be  removed  whenever  they  are  involved,  and  the 
diflflculties  of  the  operation  in  the  advanced  type  of  the  disease  are 
certainly  very  great.  All  structures  below  the  brim  of  the  pelvis  are 
bound  together  in  one  rigid,  friable  mass;  enucleation  of  the  tumour 
without  rupture  of  the  intestine  requires  the  most  painstaking  care; 
and  nothing  short  of  a  raw,  uncovered  condition  of  the  pelvis  can  be 
left  behind. 

The  fluid  in  the  peritoneal  cavity  is  either  free  and  requiring  no 
special  effort  for  its  removal,  or  it  may  be  sacculated  and  require  a 
careful  tearing  of  adhesions  for  its  relief.  Single  adhesions  should 
be  released,  but  when  the  intestines  are  bound  together  in  one  mass 
they  should  not  be  touched.  Certain  operators  advise  flushing  the 
peritoneal  cavity  in  every  case  and  the  thorough  mopping  out  of  every 
part  of  the  fluid,  while  others  would  irrigate  only  the  pus  cavities. 
The  question  of  drainage  in  these  cases  has  been  rather  definitely  set- 
tled in  favour  of  the  immediate  closure  of  the  abdomen,  unless  there 
are  distinct  pus  sacs  which  demand  drainage. 

Many  theories  have  been  advanced  with  considerable  sagacity  to 
explain  the  manner  of  the  healing  after  abdominal  section,  but  we 
are  still  without  a  positive  explanation.  It  was  first  thought  that  the 
cures  were  accounted  for  by  the  presence  of  a  "  nodular  peritonitis  " 
instead  of  the  true  tuberculous  peritonitis,  but  a  great  number  of 
cases  are  on  record  in  which  the  diagnosis  has  been  made  from  the 
tissues  or  fluid  removed  at  operation,  and  a  disappearance  of  the  tuber- 
culous process  has  been  demonstrated  at  a  later  date  by  autopsy  or  by 
subsequent  operation.  The  removal  of  the  exudate  was  supposed  to  im- 
prove the  peritoneal  vitality  and  resorptive  power  by  relieving  the  em- 
barrassment to  the  blood  and  lymphatic  circulation  (Bumm);  but  this 
is  inadequate,  since  the  dry  forms  are  also  healed  by  operation  and 
mere  tapping  does  not  often  result  in  healing.  The  use  of  ayitisep- 
tics  (iodoform,  mercuric  bichloride,  etc.),  can  not  explain  the  good 
results,  because  the  improvement  is  much  more  satisfactory  when  none 
are  used.  The  modern  surgeon  has  suggested  that  certain  bacteria 
which  develop  a  toxine  that  is  antagonistic  to  the  tubercle  bacillus  must 
gain  entrance  at  the  time  of  operation.  The  germicidal  action  of  air 
and  sunlight  on  the  tubercle  bacillus  was  suggested  by  Koch  as  an  ex- 
planation, but  it  is  apparent  that  such  action  is  only  momentary,  that 
it  can  not  possibly  reach  the  deeper  pouches  of  the  peritoneum,  and 
that  lupus  of  the  face  would  not  exist  in  the  presence  of  such  an 
action.  Warnecke  first  suggested  hypercemia  of  the  peritoneum  fol- 
lowing handling,  sponging,  flushing,  or  the  contact  of  air,  as  the  heal- 
ing factor,  and  others  insist  upon  the  antibacterial  action  of  the  exudate 
that  is  immediately  poured  out  (Sippel,  Satti).  Hildebrandt  has  dem- 
onstrated on  animals  that  a  laparotomy  can  only  have  its  full  efl'ect 
when,  in  the  natural  life  history  of  the  tuberculosis,  the  retrograde 
process  has  already  set  in;  and  he  believes  that  the  assistance  to  healing 
given  by  laf)arotorny  is  the  result  of  a  persistent  venous  liypenemia. 


698  A  TEXT-BOOK   OF  GYNECOLOGY 

The  injection  of  sterile  air  by  Nolen  can  have  no  value,  while  the 
explanation  of  Biimm  and  Buchner,  of  a  healing  by  phagocytosis  and 
alexine  formation,  may  have  some  importance.  It  is  probable  that  the 
combined  action  of  a  number  of  these  agencies  will  explain  the  healing 
that  takes  place. 

The  percentage  of  cures  following  operation  is  placed  by  Parker 
Syms  at  about  30  per  cent  as  a  result  of  a  comparison  of  statistics 
varying  from  2J:  to  80  per  cent.  Konig  reports  131  cases  in  which 
24  per  cent  were  healed  for  over  two  years,  65  per  cent  under  two 
years,  and  3  per  cent  died  after  operation.  At  any  rate,  laparotomy 
must  be  looked  upon  as  a  life-saving  measure  that  will  be  necessary  in 
a  majority  of  cases  and  having  only  the  very  low  mortality  of  3  per 
cent.  The  operation  is  not  contraindicated  in  slight  involvement 
of  the  lung,  but  should  not  be  done  when  an  acute  miliary  tuberculosis 
is  present. 


CHAPTEE  XLV 

MENSTRUATION 

Normal  menstruation — Time  of  appearance — Menstrual  cycle — Quantity  of  dis- 
charge— Character  of  the  discharge — The  inducing  cause  of  menstruation — 
The  role  of  the  uterus — The  role  of  the  Fallopian  tubes — The  role  of  the 
ovaries — The  hygiene  of  menstruation. 

Normal  Menstruation. — If  we  say  that  menstr-uation  is  a  sanguineous 
flotv  from  the  genitals  of  woman,  lasting  four  days  at  each  recurrence, 
and  appearing  at  regular  intervals  of  twenty-eight  days  from  the  dawn 
of  puberty  until  the  child-bearing  period  has  passed,  we  have  made  a  very- 
fair  definition;  but  every  separate  statement  contained  in  it  is  sub- 
ject to  many  exceptions. 

For,  in  the  first  place,  menstruation  is  not  peculiar  to  woman.  In 
her,  to  be  sure,  the  function  has  risen  to  its  highest;  but,  none  the  less, 
it  is  an  inheritance,  and  she,  in  menstruating,  is  not  unique.  In  a 
number  of  our  domestic  animals  at  the  time  of  maximum  sexual  ex- 
citement, there  is  a  very  notable  flow  of  mucus  from  the  vulva,  and  this 
mucus  is  oftentimes  loaded  with  anatomical  elements,  young  cells,  and 
a  small  amount  of  blood.  Millikin  has  observed  this  tinge  in  the  case 
of  the  cow  and  the  mare,  and  it  has  been  reported  as  present  in  the 
female  dog  and  in  a  number  of  apes  and  monkeys. 

Walter  Heape  {Proceedings  of  the  Royal  Society,  iSTo.  361)  has  given 
an  excellent  account  of  Macacus  rhesus,  an  Indian  monkey,  which  has 
a  definite  breeding  season  but  menstruates  with  regularity  through 
the  whole  year.  At  the  menstrual  period,  macacus  displays  a  certain 
congestion  of  the  skin  upon  the  abdomen,  legs,  and  tail,  and  to  these 
simian  symptoms  adds  the  strictly  ladylike  features  of  swelling  and 
congestion  of  the  nipples  and  vulva,  and  flushing  of  the  face.  At  the 
same  time,  there  is  a  discharge  of  viscid  menstrual  fluid,  mostly  white, 
but  containing  red  corpuscles,  uterine  debris,  stroma  and  epithelium. 
Menstruation  in  Semnopithecus,  as  observed  by  Mr.  Heape,  corre- 
sponds very  closely  to  that  in  macacus. 

Curiously  comparable  to  this  is  menstruation  among  the  lowest 
savages  of  southern  Africa.  James  Stirton,  in  the  Glasgoiv  Medical 
Journal,  supporting  a  contention  that  menstruation  is  a  product  of 
civilization,  says  that  in  the  lowest  tribes  accessible  to  him  he  found 
menstruation  to  be  very  scanty  and  irregular,  and  always  inaugurated 
l)y  a  prolonged  mucous  flow  wliich  never  became  highly  sanguineous. 

699 


700  ^   TEXT-BOOK   OF  GYNECOLOGY 

There  appears  to  be  a  gradation  leading  us  from  dry  mammalian 
rut  to  the  rutting  with  discharge  of  the  highly  artificialized  domestic 
animals,  thence  to  the  menstrual  rut  of  the  quadrumana,  and  thence 
to  the  highly  sanguineous  flux  of  the  human  female.  It  is  a  biologic 
fact  that  the  higher  mammals  menstruate  Avhen  in  heat;  it  is  no  slan- 
der to  say  that  woman  is  in  heat  when  she  menstruates.  Confirmatory 
of  this  is  the  fact,  often  obscured  by  the  self-control  belonging  to 
women  of  the  highest  and  most  refined  type,  that  the  beginning  of 
a  menstrual  flow  tallies  with  an  acme  of  sexual  desire,  insomuch  that 
considerations  of  modesty  and  convenience  will  not  always  deter  them 
from  absolute  solicitation  at  the  menstrual  time. 

Against  the  identity  of  menstruation  and  rutting  it  has  been  urged 
that  menstruation  continues  with  regularity  through  the  year,  whereas 
rutting  is  a  phenomenon  of  some  particular  time  of  the  year;  and  the 
fittest  answer  is  that  the  females  of  those  animals  which  have  been 
most  artificialized  by  domestication,  tend  to  come  in  heat  at  regular 
intervals  through  the  whole  year,  after  the  manner  of  women.  The 
mare,  for  example,  tends  to  come  in  heat  every  three  weeks,  and  the 
female  dog  who  escapes  pregnancy  will  also  develop  a  regular  period. 
That  is  to  say  that,  when  li^nng  under  human  conditions,  they  tend  to 
human  menstruation. 

It  should  be  noted  that  the  heat  of  wild  animals  is  determined  b}^ 
two  causes,  the  arrival  of  spring  and  the  greater  food  supply  which 
comes  after  a  time  of  relative  scarcity  in  most  climates.  Human  fore- 
thouglit  and  ingenuity  have  practically  annulled  the  influence  of  the 
seasons  and  have  made  the  supply  of  food  constant  over  the  greater  part 
of  all  the  earth.  But  where  degraded  tribes  exist  in  primitive  con- 
ditions, virtually  in  a  feral  state,  we  find  that  women  return  to  the 
animal  type  of  menstruation.  In  the  long,  bright  days  of  the  Arctic 
summer,  the  Eskimo  men  and  women  pass  into  a  state  of  ecstatic 
sexual  excitement  which  is  terminated  only  by  satiety  and  exhaustion. 
It  is  at  that  season  that  the  women  become  pregnant,  for  the  most 
part.  The  comparatively  refined  women  of  Greenland  often  cease  to 
menstruate  during  the  long  dark  winters,  and  similar  observations  have 
been  made  in  the  high  mountain  regions  of  France  and  Switzerland. 
Barnes  says  flatly  that  some  women  menstruate  only  in  warm  weather. 
The  inmiigrants  who  came  to  our  shores  forty  years  ago,  after  long 
voyages  on  short  rations,  came,  as  was  often  observed,  in  excellent 
health,  but  in  a  condition  of  amenorrhoea.  In  our  north  temperate 
zone,  it  can  be  shown  that  women  of  the  robust  type  who  nurse  their 
children  and  do  not  limit  their  fecundity,  have  a  tendency  to  bear 
children  every  second  year  in  midwinter.  So  frequently  does  this 
occur  that  it  leaves  room  to  question  whether  there  may  not  be  still  a 
breeding  season  for  the  human  female,  a  faint  fossil  relic  of  primeval 
times. 

In  a  comparative  study,  it  must  ever  be  remembered  that  perturbing 
influences  tend  to  induce  a  more  prolonged  and  uniform  sexuality  in 


MENSTRUATION  YOl 

the  human  female.  Her  purely  animal  lust  is  complicated  with  spir- 
itual affection  for  her  mate,  and  this  is  in  conformity  to  high  poetic 
ideals;  it  is  fused  with  aesthetic  ideals,  also;  it  finds  its  ethical  restraints; 
and  all  of  these  human  complications  are  only  faintly  prefigured  in 
the  psychology  of  the  lower  animals  at  the  breeding  age  and  the  breed- 
ing season.  With  woman,  primeval  sexual  instincts  are  continually 
cooled  by  prudence,  modesty,  conventional  prudishness,  and  high  intel- 
lectuality; it  is  inevitable  that  advancing  refinement,  and  even  in- 
creased comfort  in  life,  should  cause  the  phenomena  of  rutting  to 
take  on  a  less  furious  character  and,  as  a  corollary,  a  more  uniform 
character  through  the  year.  And  so  the  cycle  of  human  rutting  be- 
comes much  shortened. 

It  may  well  be  that  the  function  of  menstruation  will  disappear  in 
the  course  of  ages,  but  in  its  last  waning  recurrences  it  will  still  be 
cyclical  in  its  manifestations.  It  is  a  law  of  life  and  of  all  activity. 
The  respiratory  movements  are  rhythmic,  and  by  a  deeper  breath  at 
every  seventh  or  eighth  respiration  we  graft  rhythm  upon  rhytlim. 
There  is  a  recurrence  of  hunger  and  of  the  propensity  to  sleep  which 
is  not  in  exact  correspondence  with  the  needs  of  the  organism.  In 
healthy  persons  of  both  sexes  there  is  a  diurnal  tide  in  the  pulse  rate, 
the  respiration,  the  arterial  tension  and  the  temperature.  More  than  one 
competent  observer  has  come  close  to  a  demonstration  of  that  which  is 
inherently  probable — a  tidal  movement  in  the  adult  male  of  the  human 
species  during  which  all  vital  processes  and  the  sexual  appetite  reach  a 
climax  and  then  decline  to  a  minimum,  so  that  the  question  has  been 
seriously  raised  whether  it  is  not  true  that  men  menstruate  as  well  as 
women.  And  if  we  make  the  easy  step  from  the  physiological  to  the 
pathological,  we  find  the  same  inexorable  law  of  rhythm  in  the  periodi- 
cal recurrence  of  malarial  paroxysms  which  the  plasmodium  has  not 
fully  explained,  of  epileptic  seizures,  of  maniacal  crises,  and  in  the 
characteristic  fever  curve  of  the  acute  infectious  diseases.  Even  in  the 
highest  intellectual  activity  we  find  the  same  law,  for  the  creative  power 
of  genius  has  its  ebb  and  flow. 

The  Time  of  Appearance. — That  menstiiiation  usually  comes  with 
pubert}'  is  a  matter  of  common  knowledge.  In  the  United  States  that 
age  may  be  put  at  fourteen  years  and  six  months,  with  wide  individual 
variance  from  this  average.  Very  frequently  the  function  announces 
itself  and  is  heard  of  no  more  for  months;  irregularity  for  the  first 
year  is  too  common  to  excite  the  alarm  of  most  mothers. 

Precocious  menstruation  may  appear  even  in  infancy.  Hungry  for 
marvels,  women  will  often  bring  the  baby's  first  diaper  with  a  red 
stain  upon  it,  and  this  is  presented  for  blood  in  the  case  of  a  boy,  and 
for  menstrual  fluid  in  the  case  of  a  girl.  In  almost  every  case  the  red 
patcb  will  be  founrl  to  be  gritty  under  tbe  finger,  and  its  free  solubility 
in  warm  water  will  confirm  the  diagnosis  of  rod  urates.  Sometimes, 
however,  in  the  case  of  girls,  a  small  aniount  ol'  blood  will  be  found 
to   come    from    a    vul  vo-vagiiiilis,   wil  li    or   \\i1lioiii    ^oiiococci.      Even 


702  A   TEXT-BOOK  OF  GYNECOLOGY 

more  rarely,  granulations  exist  about  the  urethral  opening  sufficiently- 
large  and  weak  to  produce  a  stain  of  blood.  Millikin  recalls  a  very 
puzzling  case  of  a  little  girl  who  did  not  cease  to  "  menstruate  "  until 
after  a  course  of  antisyphilitic  medicine.  The  mother's  many  abor- 
tions furnished  the  clew  to  a  diagnosis,  confirmed  after  years  by  the 
child's  dentition  and  the  development  of  periosteal  nodes.  But  a 
menstrual  fioAv  from  the  uterus  of  a  healthy  child  is  not  to  be  denied. 
It  may  appear  under  the  stimulus  of  disease,  as  in  a  case  reported  by 
Gemmell  {British  Medical  Journal,  vol.  i,  1892),  where  a  healthy  girl  of 
nine  years,  not  hemophilic,  had  a  flow  of  blood,  squamous  epithelium, 
and  debris,  which  continued  five  days  following  the  height  of  the  erup- 
tion of  measles. 

There  are  many  cases  reported  showing  the  menstrual  tendency  so 
strong  that  no  stimulus  of  acute  disease  is  needed  to  bring  on  the  flow 
precociously.  Millikin  knows  a  case  of  two  girls  in  whom  puberty 
came,  by  gradual  and  symmetrical  development,  at  the  ages  of  eight 
and  eight  and  a  half  years,  respectively.  Here,  menstruation  was  a 
mere  incident  to  perfect  womanhood,  for,  though  these  little  women 
had  not  attained  their  full  stature,  they  had  acquired  rich  voices,  they 
cared  little  for  children  of  their  own  ages,  one  of  them  suddenly  be- 
came very  averse  to  school,  and  the  other  attended  to  household  matters 
with  womanly  enthusiasm. 

More  extreme  cases  may  be  cited,  but  here  we  trench  upon  the  mon- 
strous or  the  pathologic.  Plumb  (Neiv  York  Medical  Journal,  June 
5,  1897)  reports  the  case  of  a  child  that  weighed  9  pounds  at  birth, 
had  genitalia  similar  to  those  of  a  girl  of  seven  years,  had  pubic  hair, 
but  none  in  the  axilla,  and  had  a  clitoris  an  inch  and  a  quarter  in 
length  and  of  a  diameter  of  half  an  inch.  The  mammae  were  an  inch 
in  thickness  and  an  inch  and  a  half  in  diameter.  Bathing  the  breasts 
caused  erection  of  the  clitoris;  contact  of  clothing  with  the  clitoris 
caused  a  complete  orgasm.  Amputation  of  the  clitoris  relieved  her 
of  reflex  nervous  disturbance.  At  six  weeks  she  began  to  menstru- 
ate, and  so  continued  until  the  age  of  si^  months  when  the  report  was 
made. 

Irion  {op.  cit.,  August  15,  1896)  gives  account  of  a  girl  of  9  pounds' 
weight  at  birth,  with  breasts  and  mons  veneris  well  developed.  She 
menstruated  at  the  age  of  seven  days,  the  flow  continuing  four  days. 
A  month  later  there  was  no  flow,  but  from  that  time  until  the  child 
was  ten  months  old  she  was  reported  "  regular." 

Wladimiroff  {Arcliiv  fitr  KinderlieiTkunde,  1897)  reports  the  case 
of  a  rhachitic  girl,  six  and  a  half  years  old,  4  feet  high,  weighing 
50  pounds.  Her  breasts,  pubic  hair,  voice  and  modesty,  all  proclaimed 
her  a  little  woman.     She  had  menstruated  once. 

Klein  {Deutsche  medicinische  Wochenschrift,  1899,  'No.  3)  gives  an 
account  of  a  girl  of  ten  months  who  had  been  separated  from  her 
parents  up  to  that  age.  She  was  then  found  to  be  menstruating.  She 
menstruated  regularly  for  nine  months.     Then  she  had  amenorrhcea 


MENSTRUATION  703 

for  four  months,  and  then  menstruated  for  seven  months.  At  that  time 
she  had  an  attack  of  measles  and  ceased  to  menstruate  for  many 
months  up  to  the  time  of  the  report.  She  was  a  delicate  child  of  good 
mental  development.  Her  breasts  were  of  womanly  shape  and  her 
genitals  were  large,  with  pubic  hair. 

Howie  {Year  Book,  Gould,  1898)  reports  the  case  of  a  girl  who  men- 
struated from  the  age  of  three  years  and  fourteen  days.  At  each  period 
she  was  languid  and  suffered  malaise.  She  had  pubic  hair  and  promi- 
nent breasts. 

Morse  {op.  cit.)  reports  the  case  of  a  girl  who  began  to  menstruate 
at  the  age  of  nine  months. 

Price  {op.  cit.)  gives  a  case  in  which  the  child  menstruated  from 
the  age  of  four  years.  Pubic  and  axillary  hair  appeared  at  eighteen 
months.     Her  breasts  and  bodily  contour  were  womanly. 

Lopez  {Revista  de  la  Sociedad  Medica  Argentina)  reports  the  case 
of  a  child  of  five  years  which  menstruated  from  the  age  of  eighteen 
months.  Each  flux  was  of  from  three  to  five  days'  duration.  The  ex- 
ternal appearances  were  those  of  maturity.  The  little  creature  was 
cursed  with  ardent  sexual  passions. 

Eein  exhibited  before  the  Kieff  Obstetrical  Society  a  girl  of  six 
years  who  had  menstruated  regularly  for  a  year.  The  breasts  and  ex- 
ternal genitalia  were  appropriate  to  a  girl  of  thirteen  or  fourteen  years. 
The  abdomen  was  enlarged^,  and  a  fluctuating,  thick-walled  cyst  was 
diagnosticated. 

Sometimes  the  ripe  femininity  of  these  little  creatures  is  attested  by 
maternity.  Thus,  McLaury,  of  New  York  city  {American  Jouryial  of 
Obstetrics,  1887),  sent  a  girl  of  thirteen  years  to  a  lying-in  hospital. 
Prom  her  earliest  recollection  she  had  cohabited  with  men  and  boys. 
It  is  an  interesting  fact  that  she  was  one  of  four  children  born  to  an 
unmarried  woman. 

In  1858  there  was  a  young  mother,  not  quite  eleven  years  old,  living 
at  the  public  charge  at  Taunton,  Mass. 

Dr.  Gleaves,  of  Virginia,  has  reported  the  case  of  a  girl  who  at 
the  age  of  ten  years  and  two  months  was  delivered  of  a  child  of  five 
pounds.  She  had  menstruated  from  the  age  of  five  years.  She  had  no 
mammary  development,  and  her  baby,  during  its  short  life  of  one 
week,  was  suckled  by  its  grandmother,  who  had  a  child  of  only  a  few 
months. 

These  last  cases  might  hardly  be  called  exceptional  in  warm  coun- 
tries where  men  and  women  are  so  soon  ripe  and  so  soon  rotten.  In 
Ceylon  a  youth  attains  his  majority  at  sixteen  years  and  one  may  find 
the  girls  mature  at  from  eight  to  fourteen  years.  Even  in  Mexico  it 
is  not  uncommon  to  meet  with  grandmothers  who  are  but  little  be- 
yond the  age  of  twenty  years,  and  some  cases  fall  much  witliin  this 
limit.  One  author,  representing  no  extreme  views,  has  stated  that 
the  average  age  of  first  menstruation  is  twelve  years  at  the  tropics,  and 
sixteen  years  at  the  coldest  civilized  regions. 


704  A   TEXT-BOOK  OF   GYNECOLOGY 

The  Menstrual  Cycle. — The  menstrual  month  is  a  myth  which  has 
no  other  basis  than  the  obscure  moon-worship,  latent  in  our  race.  For 
each  woman,  a  definite  and  precise  cycle  is  usually  established,  early  in 
her  menstrual  life,  but  that  cycle  is  seldom  measured  by  precisely 
twenty-eight  days.  Vast  numbers  of  women  menstruate  scantily  every 
two  weeks  and  enjoy  perfect  health.  Upon  inquiry,  it  will  be  found  that 
man}^  women  menstruate  every  three  weeks.  A  very  large  number  of 
women  are  delighted  to  know  that  they  conform  to  the  classic  period 
of  twenty-eight  days,  but  make  their  reckoning  from  the  end  of  one 
period  to  the  beginning  of  the  next,  so  that  they  really  have  a  cycle 
of  about  thirty-three  days.  In  the  same  group  are  those  who  compla- 
cently declare  that  they  are  regular  as  the  clock  because  they  men- 
struate always  on  the  same  day  of  the  calendar  month.  Millikin  knows 
a  case  of  two  sisters  who  were  in  excellent  health,  but  much  dis- 
turbed because  of  menstrual  irregularity,  and  it  took  much  patient 
investigation  to  determine  the  fact  that  they  had  periods  of  thirty- 
seven  and  forty-nine  days,  respectively. 

There  is,  in  truth,  no  normal  period  of  menstruation  except  in  the 
sense  that  there  is  an  average  period  of  about  twenty-eight  days,  from 
which  most  women  depart  widely.  Exact  conformity  to  this  period 
brings  no  added  grace,  health,  or  fecundity;  and  contrary  to  the  com- 
mon belief  among  women,  departure  from  it  brings  no  peril.  As  a 
general  rule,  women  highly  refined  and  of  delicate  tissues  will  men- 
struate more  frequently,  while  coarser,  more  robust  women  will  men- 
struate less  frequently. 

The  Quantity  of  the  Dischargee. — At  each  menstrual  period,  the 
human  female  loses  from  2  to  l-f  ounces  of  fluid.  As  the  estimate  must 
be  made  from  the  collection  of  a  few  hours,  it  is  not  surprising  that 
tlie  range  of  variation  should  be  so  great.  Individual  dift'erences  are 
known  to  be  very  great,  for,  while  one  healthy  woman  will  have  merely 
enough  discharge  to  stain  her  clothing,  another,  equally  healthy,  with 
like  fixity  of  habit,  will  soak  her  cloths  for  two  or  three  days. 

No  other  mammalian  female  loses  so  much  blood  as  woman.  This 
we  explain,  first,  by  the  fact  that  the  reproductive  apparatus  of  the 
lower  animals  has  no  other  purpose  than  reproduction,  whereas,  in 
the  highest  of  mammals  it  ministers  to  complex  loves  and  likings  and 
lusts  which  are  only  incidentally  or  accidentally  reproductive.  If  the 
stimulus  brought  to  bear  upon  the  genitalia  of  the  human  female  were 
ten  thousand  times  less  than  it  is,  it  Avould  still  suffice  for  the  perpetua- 
tion of  the  species.  There  is  therefore  an  abnormally  high  functional 
activity  of  the  human  uterus  and  all  that  pertains  to  it,  if  we  allow 
the  lower  animals  to  fix  the  norm,  and  with  this  goes  abnormal  conges- 
tion and  a  tendency  to  increased  leakage. 

In  the  second  place,  it  may  be  observed  that  the  erect  posture  of 
the  human  female  distinctly  invites  a  free  supply  of  blood  to  the  pelvic 
organs  and  hinders  its  return  to  the  heart.  Such  indeed  is  the  law  of 
all  parts  of  the  body  lower  than  the  heart.     Man,  the  monarch  of  all 


MENSTRUATION  705 

living  things,  erects  himself  in  appropriate  attitude  and  pays  the  pen- 
alty of  his  arrogance  by  suffering  from  varices,  hemorrhoids  and  pre- 
carious nutrition  of  his  hinder  legs:  his  poor  mate,  to  these  lesser 
plagues,  adds  her  characteristically  profuse  menstrual  flow.  We  may 
add,  as  a  third  consideration,  that  the  delicate  tissues  of  the  highly 
civilized  woman  are  poorly  able  to  resist  the  influences  which  tend  to 
leakage  of  blood  at  the  menstrual  time. 

In  temperate  zones  the  average  duration  of  menstruation  is  about 
four  days  and  a  half.  In  any  locality  may  be  found  great  numbers  of 
women  who  habitually  menstruate  two  days,  and  as  many  who  men- 
struate seven  days. 

Character  of  the  Discharge. — There  are  occasional  cases  which  fur- 
nish what  has  been  well  called  white  menstruation.  The  subjects  usu- 
ally announce  themselves  as  suffering  from  a  leucorrhoea  which  is 
"  very  weakening."  Investigation,  after  excluding  gushes  of  fluid 
from  diseased  tubes,  and  after  establishing  the  periodic  character  of 
the  discharge,  will  properly  refer  it  to  an  attempt  at  menstruation 
which  goes  no  farther  than  engorgement  and  superseeretion  of  the 
uterine  glands.  White  menstruation  is  not  pathologic  and  certainly 
does  not  demand  surgical  treatment. 

The  ordinary  menstrual  fluid  is  composed  of  mucus  which  comes  at 
first  from  the  uterus  alone;  at  a  later  stage,  the  vaginal  glands  are 
also  active  and  pour  out  their  share  of  mucus.  At  an  early  stage, 
blood  is  mixed  with  this  mucus,  and  the  fluid  takes  on  the  tint  of 
venous  blood,  or,  by  rapid  decomposition  of  corpuscles,  it  becomes 
brown  or  black.  Ciliated  epithelium  from  the  uterus  is  abundant, 
and  a  small  quantity  of  epithelium  from  the  vagina  is  also  present. 
Eemains  of  the  endometrium  are  to  be  found  abundantly.  Fatty  acids 
are  present  to  give  to  the  fluid  its  characteristic  odour,  and  to  prevent 
the  coagulation  of  the  menstrual  blood.  When  the  blood  is  present 
in  high  proportion,  possibly  because  of  a  low  amount  of  mucus  and 
acids,  clots  form,  to  the  dismay  of  the  subject.  Of  all  the  compo- 
nents of  the  menstrual  fluid,  the  blood  is  probably  the  least  impor- 
tant. The  hemorrhage  is  merely  an  untoward  accident  occurring  in 
the  course  of  important  significant  changes  within  the  uterus. 

That  menstruation  is  an  excretory  process  during  which  "  bad 
blood  "  and  nameless  poisons  are  excreted,  is  an  error  possessed  of 
notable  vitality,  for  it  has  lived  long  and  it  dies  hard.  No  one  has 
suggested  a  mode  or  an  avenue  of  elimination  for  this  poison  in  men, 
boys,  old  women,  pregnant  women,  little  girls  or  women  in  whom  sur- 
gery has  brought  on  an  artificial  menopause;  no  one  has  detected  it 
in  the  discharges;  no  one  has  pointed  out  any  essential  difference 
between  women  wlio  menstruate  freely  and  those  who  menstruate 
scantily.  Nevertheless  the  fancied  peccant  substances  will  remain 
in  literature  for  another  century. 

Millikin  knows  of  courtesans  enjoying  excellent  health  who,  with 
more  knowledge  of  thnir  trade  tban  of  transcendental  pathology,  have 
40 


706  A  TEXT-BOOK  OF   GYNECOLOGY 

learned  the  trick  of  suppressing  the  menses  at  will  by  the  use  of  tightly 
packed  sponges.  A.  W.  Parsons,  of  Northampton,  Mass.,  has  taught 
many  patients  to  tampon  the  vagina,  partly  for  the  comfort  and  neat- 
ness secured,  and  partly  to  limit  the  amount  of  discharge  as  might  be 
thought  good.  In  1888  Gehrung  recommended  {American  Journal  of 
Obstetrics)  the  use  of  an  alum-soaked  tampon  to  be  retained  for 
forty-eight  hours  unless  there  should  be  leaking  through  or  around  it. 
He  uses  this  tampon  boldly  to  abbreviate  or  lessen  the  flow  at  his 
pleasure  or  to  hasten  the  menopause.  It  was  his  deliberate  purpose 
to  reduce  the  flow  to  a  limit  of  from  2  to  -1  ounces,  and  this  was  ac- 
complished in  his  therapy  without  a  hint  of  harm.  Loewenthal,  in 
June,  1888,  advocated  the  restraint  of  menstruation  by  intrauterine 
injections  of  hot  water,  or,  occasionally,  of  iced  water.  He  had 
greatly  benefited  18  cases  of  chlorosis  by  suppressing  menstruation  for 
from  three  to  five  months. 

The  Inducing  Cause  of  Menstruation. — Then,  throwing  aside  the 
notion  that  the  menstrual  fluid  is  cast  out  by  an  active  effort  of  the 
system  to  rid  itself  of  a  poison  or  a  group  of  poisons,  we  inquire  fur- 
ther into  the  inducing  causes.  From  the  very  beginnings  of  medical 
literature,  there  is  a  hint  that  the  blood  of  the  human  female  was 
rich  enough  to  force  an  overflow  every  four  weeks,  this  capacity  for 
plethora  being  born  and  bred  in  her  for  the  benefit  of  her  pos- 
sible offspring.  Without  a  fact  to  support  it,  this  teleologic  theory 
was  unchallenged  until  late  in  the  present  century.  More  recently 
a  very  popular  theory  was,  that  Nature  prepared  a  decidua  for  the 
coming  ovum  and  that,  when  impregnation  failed,  for  any  cause, 
she  entered  upon  a  house-cleaning  process  which  involved  the  cast- 
ing off  of  the  decidua,  and,  as  Christopher  Martin  said,  poured  out 
a  flood  of  blood  from  the  turgid  capillaries  to  wash  away  the  use- 
less debris. 

Of  late,  some  have  been  strangely  impressed  with  the  fact  that 
the  uterus  has  a  rich  nervous  supply,  its  sympathetic  fibres  re-en- 
forced by  spinal  filaments  given  off  from  the  abdominal  splanchnics, 
which  send  filaments  to  the  uterus  by  way  of  the  hypogastric  plexus, 
and  re-enforced  also  by  fibres  from  the  pelvic  splanchnics  which  also 
pass  through  the  hypogastric  plexus  on  their  way  to  the  generative 
organs,  the  bladder,  and  the  rectum.  It  has  caused  admiration,  also, 
that  the  uterus  has  its  own  ganglia,  giving  it  independent  movement,, 
even  when  dissevered  from  the  body,  and  it  has  been  announced  that 
the  uterus  has  anabolic  nerves  to  retard,  and  katabolic  nerves  to  accel- 
erate, its  metabolism. 

But  in  all  this,  the  uterus  is  not  singular;  its  nervous  organiza- 
tion is  in  every  way  comparable  to  that  of  other  important  viscera, 
for  we  believe  that  they  all  have  motor,  sensory,  vasomotor,  and 
trophic  nerves.  That  the  function  of  menstruation  involves  nervous 
apparatus  is  true,  by  all  analogies,  but  that  it  is  in  any  special  sense 
a  nervous  phenomenon,  is  not  true. 


MENSTRUATION  70Y 

Ott  (Wiener  medizinische  Presse;  Archiv  fiir  Gyndhologie)  has 
shown,  as  have  man}'  other  observers,  that  there  'are  slight  changes  in 
temperature,  pulse,  blood  pressure,  and  respiration  through  the  men- 
strual cycle,  and  that,  carefully  followed,  these  indicate  that  vital 
activity  is  at  a  maximum  just  before,  or  during,  menstruation.  Gath- 
ering up  the  large  array  of  facts  that  show  these  trivial  changes  in 
vital  processes,  and  show,  also,  that  the  daily  excretion  of  urea  and 
of  carbonic  acid  is  subject  to  slight  variations  through  the  menstrual 
cycle,  Stephenson  has  held  that  the  wave  of  rising  vitality  is  influ- 
enced by  a  menstrual  centre,  wholly  hypothetical  as  yet,  which  is,  or 
ought  to  be,  situated  somewhere  in  the  lumbar  portion  of  the  spinal 
cord,  and  which  acts  rhythmically  to  bring  on  Stephenson's  wave  and 
the  accompanying  menstrual  flow.  No  explanation  has  yet  been 
offered  for  the  rhythmic  action  of  the  supposed  centre.  The  advo- 
cates of  this  theory  of  menstruation  are  troubled  little  by  the  fact 
that  similar  waves  are  to  be  detected  in  the  lower  animals  and  in  the 
males  of  our  own  species,  and  the  doctrine  may  well  be  dismissed  in 
the  words  of  Stephenson,  himself,  who  reduces  the  whole  theory 
ad  absurdum  by  his  comment  on  the  varying  intensity  of  vital  phe- 
nomena in  the  male :  "  it  is  therefore  evident  that  the  phenomena 
belong,  not  to  the  function  of  menstruation,  but  to  a  general  law  of 
vital  energy." 

A  case  of  Eushton  Parker's  may  here  be  quoted  with  profit.  He 
was  consulted  by  a  couple  who  had  been  married  eight  months  and 
had  never  accomplished  coitus.  The  husband  was  twenty-four  years 
old,  and  nothing  could  be  seen  amiss  with  him  save  that  he  had  "  a 
cowed  look."  He  denied  any  practice  of  masturbation  and  also  denied 
any  sexual  feeling.  All  organs  were  normal,  save  that  the  testes  were 
small  and  soft.  His  wife  had  observed  that  he  had  a  sanguineous 
discharge  for  three  days  out  of  every  month.  He  readily  agreed  to  a 
separation  and  a  division  of  income.  {British  Medical  Journal, 
March,  1899.) 

Napier  has  suggested  that  the  pressure  of  the  enlarged  utricular 
glands  of  the  endometrial  mucous  membrane  may  be  the  stimulus, 
acting  upon  the  terminal  nerve  filaments,  to  induce  menstruation,  and 
he  has  pointed  out  the  fact  that  the  time  required  for  such  growth  in 
the  constantly  renewed  mucous  membrane,  would  correspond  rudely, 
with  the  intermenstrual  period. 

But  we  need  not  look  for  any  accurate,  mechanical  explanation  of 
this  function.  We  can  do  no  better  in  the  present  state  of  our 
knowkidge  than  accept  menstruation  as  a  habit  which  has  been  nailed 
upon  our  race  by  heredity,  and  which  is  for  us  an  ultimate  biologic 
fact.  This  hypothesis  meets  all  cases  of  menstruation  without  ovula- 
tion, all  cases  of  menstruation  after  the  removal  of  the  pelvic  geni- 
talia and  the  destruction  of  their  nervous  apparatus,  all  cases  of 
menstruation  in  infants  and  in  withered  old  women,  all  cases  of  mcn- 
stnuition  in  men,  and  all  cases  of  vicarious  menstruation. 


708  A   TEXT-BOOK  OF   GYNECOLOGY 

The  Role  of  the  Uterus. — It  is  often  said,  with  essential  truth, 
that  "  menstruation  marks  tlie  destruction  of  the  endometrial  mucous 
membrane."  If  it  does  not  do  all  this,  it  certainly  marks  the  destruc- 
tion of  its  highly  organized,  thickened  superficial  part,  the  decidua 
menstrualis.  The  endometrium  is  a  mucous  membrane  highly  special- 
ized, to  be  sure,  but  not  more  so  than  the  mucous  membranes  of  the 
intestines  and  the  stomach,  and  it  certainly  does  not  depart  from  the 
type  so  far  as  does  the  conjunctiva.  It  is  distinguished  anatomically 
by  its  delicate  stroma  and  by  its  abundant  glandular  elements;  it  is 
distinguished  physiologically  by  its  power  of  self-renewal  which  recalls 
continually  the  fcetal  tissues,  the  cells  of  malignant  growths,  and  the 
tissues  of  the  crustacea  and  lowlier  forms  of  animal  life.  Delicate 
as  it  is,  it  is  not  thinner,  but  thicker,  than  most  mucous  membranes 
during  the  greater  part  of  the  menstrual  month.  It  is  essentially  a 
uterine  lining,  for  it  does  not  extend  downward  into  the  cervix,  or 
into  the  Fallopian  tubes.  At,  or  before,  the  menstrual  time,  it  under- 
goes fatty  and  granular  degeneration  and  is  cast  off  in  great  part, 
and  when  discarded,  it  leaves  the  blood  vessels  in  its  basal  substance 
unsupported.  That  the  whole  mucous  membrane  is  discarded,  is  not 
believed;  regeneration  is  accomplished  by  the  remaining  glands  in 
the  deeper  layers,  and  is  complete  in  about  ten  days  after  the  general 
wreck  has  been  effected. 

These  facts  have  been  derived  from  the  studies  of  many  observers, 
but  unfortunately  they  have  been  somewhat  vitiated  by  the  post- 
mortem delay  in  preparation  of  specimens,  or  by  the  impress  of  lethal 
accident  or  disease.  For  this  reason  we  turn  to  our  quadrumanous 
sisters  and  follow  the  admirable  epitome  of  Walter  Heape's  labours, 
prepared  by  Lawrence  for  the  Ohio  State  Medical  Society  in  1897.  It 
will  be  understood  that  the  researches  cover  studies  made  upon  the 
lowly  Cynomorpha,  but  mostly  upon  the  higher  group  of  Antliropomor- 
pha  which  includes  the  lemurs,  chimpanzees,  orangs,  and  the  gorilla. 

Heape  divides  the  menstrual  cycle  into  four  stages:  1.  Eest; 
2.  Growth;  3.  Degeneration;  4.  Eecuperation. 

During  rest  there  is  only  one  layer  of  cubical  columnar  cells,  with 
round  nuclei.  The  protoplasm  of  cells  is  continuous  with  the  proto- 
plasm of  the  stroma  network  beneath.  This  epithelium  is  continu- 
ous with  that  of  the  glands  beneath.  The  stroma  has  round  nuclei 
embedded  in  a  continuous  network  of  protoplasm. 

During  growth  the  stroma  nuclei  are  much  increased  by  amitotic 
division  and  by  fragmentation ;  this  causes  swelling  of  the  superficial 
portion  of  the  mucosa.  Nuclei  now  become  fusiform.  Deep  portions 
of  stroma  are  not  changed.  Interglandular  tissue  swells,  but  the 
glands  are  not  much  altered.  The  epithelium,  lifted  by  the  dense 
layer  of  nuclei,  becomes  less  dense.  The  blood  vessels  below  the  epi- 
thelium undergo  hyperplasia.  The  more  superficial  layers  of  the 
stroma  swell.  Glands  are  widened.  Many  stroma  nuclei  are  re- 
duced in  size,  but  the  mucosa  as  a  whole  is  increased  in  thickness. 


MENSTRUATION  70^ 

During  degeneration  there  appears  hypertrophy  of  the  epithelium, 
the  stroma,  and  tlie  walls  of  the  blood  vessels.  Afterward,  there  is 
amyloid  degeneration  of  the  superficial  layers  of  the  mucosa.  In  this 
layer,  congested  capillaries  break  down  with  extravasation.  At  each 
point  of  rupture,  red  and  white  cells  are  swept  into  the  stroma.  The 
extravasated  blood  collects  in  lacunaj  in  the  stroma,  and  these  lacunas, 
extending  and  dissecting,  lift  the  epithelium.  At  this  time,  the  deep 
portions  of  the  mucosa  are  not  infiltrated,  and  neither  red  nor  white 
cells  are  found  free.  Leucocytes  and  stroma  cells  degenerate;  the 
epithelium  shrivels;  lacunae  grow  larger;  degenerated  epithelium  is 
ruptured;  blood  is  free  in  the  uterine  cavity.  If,  in  any  case,  the 
lacuna  surround  a  gland,  the  gland  is  washed  away.  In  this  later 
stage  of  degeneration,  leucocytes  increase  the  number  of  their  nuclei 
but  are  not  seen  to  divide.  Denudation  is  now  complete ;  all  the  epi- 
thelium, portions  of  glands  and  sometimes  whole  glands,  and  even 
small  portions  of  the  stroma,  are  lost  in  the  flood.  The  inner  surface 
of  the  uterus  appears  ragged,  with  layers  of  masses  of  blood  here  and 
there.     The  deep  layers  of  the  stroma  are  wholly  intact. 

In  regeneration,  the  epithelium  is  formed  anew  by  extension  from 
the  torn  edges  or  by  the  transformation  of  the  stroma  cells.  N'ew 
capillaries  are  formed  and  new  blood  vessels.  New  glands  are  formed 
by  the  infolding  of  epithelium.  Extravasated  blood  is  absorbed.  Re- 
pair is  complete ;  rest  is  at  hand. 

The  Role  of  the  Fallopian  Tubes. — It  is  positively  known  by  the 
dissection  of  women  who  have  died  by  violence  at  different  stages  of 
menstruation,  that  the  Fallopian  tubes  are  much  congested  during 
menstruation  and  that,  in  most  cases,  at  least,  they  are  filled  with 
fluid  that  contains  blood  corpuscles  and  epithelial  cells.  Robinson, 
of  Chicago,  after  a  study  of  800  tubes  from  operative  and  post-mor- 
tem cases  (American  Journal  of  Obstetrics,  September,  1891),  confirms 
this,  and  expresses  his  belief  that  the  ovum  is  more  easily  preserved 
and  wafted  through  the  tube  while  thus  filled  with  fluid. 

Besides  what  is  known,  it  is  certainly  very  probable  that  the  con- 
gestion and  contraction  of  the  tube  leads  to  its  erection,  and  that, 
during  some  part  of  menstruation,  it  has  a  gross  movement  of  peri- 
stalsis, while  the  cilia  of  its  epithelium  become  active.  That  the 
tubes  have  much  to  do  with  the  excitation  which  precipitates  men- 
struation, might  well  he  supposed  from  the  fact  that  they  are  con- 
tinuous with  the  uterus,  and  the  additional  fact  that  they  have  a 
nerve  supply  identical  with  that  of  the  fundus.  Tait  says  that  90 
per  cent  of  cases  will  not  even  menstruate  once,  after  the  removal  of 
the  tubes. 

The  Role  of  the  Ovaries.— Some  have  admitted  the  theory,  wholly 
fanciful  in  the  present  state  of  our  knowledge,  that  the  ovary  is,  in 
part,  a  ductless  gland  and  that  its  secretion,  having  accumulated  in 
the  tissues  of  the  body  to  a  certain  saturation  becomes  the  proper 
stimulus  for  menstruaiion. 


710  A  TEXT-BOOK  OP   GYNECOLOGY 

Waiving  this  doctrine,  which  is  capable  neither  of  proof  nor  dis- 
proof, we  may  say  that  the  ovary  has  but  one  function,  viz.,  ovula- 
tion, the  production  of  ovules  whose  highest  destiny  is  to  be  fructi- 
fied in  the  Fallopian  tube  and  developed  in  the  uterus. 

It  is  a  matter  of  regret  that  the  term  ovulation  is  a  vague  one. 
It  is  used,  commonly,  to  comprise  processes  which  cover  much  time, 
possibly  months.  We  have  reason  to  believe  that  it  takes  long  for 
the  young  Graafian  follicle  to  assert  itself,  deep  in  the  stroma  of  the 
ovary,  and  still  more  time  before  it  appears  on  the  surface  of  the 
ovary  as  a  mass  of  vascular  loops,  and  yet  more  time  before  the  wall 
becomes  nonvascular,  fatty  and  friable,  for  the  escape  of  the  ovule. 
And  even  then,  according  to  the  notions  of  some,  ovulation  is  not 
accomplished  until  the  Fallopian  tube  receives  the  ovule  and  sends  it 
to  the  uterus. 

Making  the  term  cover  only  the  latter  part  of  this  long  process, 
however,  we  put  upon  it  a  time  limit  of  days  rather  than  weeks,  and 
come  upon  a  wilderness  of  doctrines  as  to  the  relation  of  ovulation 
and  menstruation. 

It  is  held  by  Pfliiger  and  his  followers  that  menstruation  is  a 
result  of  a  nervous  discharge  caused  by  the  bursting  of  a  Graafian 
follicle  and  the  liberation  of  an  ovule.  Eaciborsky  found  rij)e  or  rup- 
tured follicles  in  healthy  and  menstruating  women  who  had  met  with 
sudden  death,  as  did  Leopold,  also,  and  their  opportunities  for  inves- 
tigation were  ample.  Unfortunately  for  the  theory,  they  also  found 
many  ripe  follicles  unruptured.  Walter  Heape  puzzles  us  by  a  state- 
ment that  in  Macacus  rhesus  the  breeding  season  is  strictly  limited, 
but  that  menstruation  continues  regularly  all  the  year  round.  Out  of 
16  cases  he  has  found  a  recently  discharged  follicle  in  only  1  case.  He 
has  not  seen  a  clot  in  a  follicle  in  any  case.  His  researches  on  Semno- 
pithecus  agree  with  these  observations,  and  lead  to  a  conclusion  that 
ovulation  and  menstruation  have  no  relation  in  these  species.  Leo- 
pold's studies  were  made  upon  twenty  pairs  of  ovaries  of  women  whose 
menstruation  was  recorded,  and  he  could  only  say  that  rupture  took 
place  most  frequently  at  menstrual  periods,  but  might  occur  at  any 
time. 

It  is  held  also,  by  some,  that  the  passage  of  the  ovule  through  the 
Fallopian  tube  is  the  immediate  stimulus  for  menstruation.  This 
is  not  inherently  impossible,  for,  as  we  have  remarked,  the  nervous 
and  muscular  anatomy  of  the  tubes  makes  them  almost  one  with  the 
menstruating  organ,  the  uterus.  But  we  are  barred  from  dogma- 
tism here  by  our  ignorance  of  the  duration  of  the  transit  of  the  ovule 
through  the  tube,  for  the  authorities  vary  in  their  estimate  from  one 
day  to  eight  days. 

We  do  not  even  know  whether  the  escape  of  an  ovule  from  the 
ovary  and  its  journey  to  the  uterus  precede  or  follow  menstruation. 
ISTaegele  taught  that  the  ovum  could  live  in  the  newly  prepared  uterus 
for  some  time  after  menstruation  was  completed,  and  that,  failing  to 


MENSTEUATION  711 

be  fertilized,  it  was  cast  off  with  the  decidua  at  the  next  menstrua- 
tion. Loewenthal's  doctrine  is  not  far  from  this,  for  he  teaches  that 
the  ovule  always  embeds  itself  in  the  endometrium  and  stimulates  the 
formation  of  the  decidua  menstrualis;  at  a  later  date,  if  still  unfer- 
tilized, its  death  brings  about  that  congestion  which  ends  in  menstru- 
ation, though  he  holds  all  hemorrhage  to  be  accidental  and  pathologic. 
(Archiv  fur  Gynakologie,  Bd.  xxiv,  p.  2.)  Barnes  also  taught  that  the  un- 
fertilized ovum,  of  some  considerable  age,  is  cast  off  with  the  decidua 
menstrualis,  but  he  conceived  the  plausible  idea  that  there  was  habit- 
ually another  ovule  on  the  road  to  the  uterus  at  the  time  of  men- 
struation. 

This  jungle  of  theories  will  not  be  cleared  until  we  master  funda- 
mental facts  which  at  present  are  beyond  us.  We  need,  first,  to  col- 
lect all  the  ovules  which  pass  from  a  woman,  but  their  fragility  and 
their  microscopical  dimensions  will  forever  forbid  such  investigation. 
We  need,  secondly,  to  be  able  to  read  the  record  of  ovulation  which 
is  left  in  the  corpus  luteum ;  but  Cohnstein  is  not  alone  when  he  de- 
clares that  we  have  no  means  of  estimating  definitely  the  age  of  one 
of  these  bodies. 

We  are  therefore  obliged  to  return  to  the  principle  enunciated  in 
a  former  section,  and  to  say  that  menstruation  is  a  habit  of  the  female 
organism,  inherited  and  fixed  beyond  her  present  needs,  and  to  that  we 
add  that  ovulation  may  occur  at  any  part  of  the  menstrual  period 
cycle.  Avoiding  any  more  definite  creed,  we  are  not  dismayed  by  the 
following  anomalous  cases  which  are  entirely  inexplicable  on  other 
theories  of  menstruation  and  ovulation. 

In  girlhood,  and  even  in  childhood,  ovulation  is  active  without 
menstruation,  and  is  sometimes  attested  by  pregnancy  before  the 
menses  have  appeared.  Eobinson,  of  Chicago  (AmeTican  Journal  of 
Obstetrics,  September,  1891),  says  that  an  examination  of  800  ovaries 
convinces  him  that  ovulation  begins  before  birth  and  continues  into 
old  age. 

Conception,  implying  ovulation,  occurs  in  many  nursing  women 
who  do  not  menstruate. 

Menstruation  occurs  in  some  exceptional  women  only  during  preg- 
nancy. 

Menstruation  occurs  exceptionally  after  the  removal  of  the 
ovaries. 

Girls  and  other  young  mammals  have  ovules  even  at  birth,  long 
before  the  period  of  menstruation. 

De  Sinety  found  a  fresh  corpus  luteum  in  a  young  woman  who  had 
died  of  phthisis,  though  she  had  not  menstruated  for  many  months. 
Vermeil  and  others  have  reported  similar  cases. 

It  is  known  that  some  women  who  have  long  passed  the  meno- 
pause, ovulate. 

In  rare  cases  women  who  have  ceased  to  menstruate  become  preg- 
nant. 


712  A  TEXT-BOOK  OF   GYNECOLOGY 

The  Hygiene  of  Menstruation. — The  primitive  man  looked  upon 
his  genitalia  and  those  of  his  mate  with  worshipful  regard,  first,  as  a 
fetish,  and  later,  as  an  incarnation  of  the  creative  principle  in  Nature. 
Most  women,  and  even  some  men  with  microscopes,  have  failed  to  out- 
grow this  savage  theology,  and  upon  small  knowledge  of  the  genitalia 
have  grafted  an  incredible  mass  of  barbaric  superstition  and  crude  folk- 
lore. More  or  less  vaguely,  women  hold  to  the  belief  that  menstruation 
is  a  season  of  peril,  and  the  general  drift  of  the  best  teaching  is  to 
the  erroneous  opinion  that  menstruation  is  a  pathologic  process  which 
must  be  skilfully  guided  to  an  end  by  the  craft  of  the  physician.  It 
would  be  well  if  this  had  definite  form,  for  then  it  would  become  vul- 
nerable and  absurd ;  as  a  matter  of  fact  it  survives  in  misty  form  in 
the  subliminal  consciousness  of  the  race,  beyond  the  reach  of  logic  or 
persuasion. 

Menstruation  being  a  perfectly  innocuous,  physiologic  process,  it 
may  be  said  that  the  hygiene  of  menstruation  is  the  hygiene  of  all  the 
year  round.  The  woman  who  conserves  her  general  health  and  main- 
tains herself  in  the  highest  possible  vigour  has  done  all  that  can  be 
done  to  make  menstruation  safe  and  easy. 

In  negation,  we  will  say  that  there  is  no  need  for  putting  the 
young  girl  to  bed  during  her  first  few  periods,  and  still  less  excuse  for 
putting  a  poultice  on  her,  as  a  distinguished  author  has  recommended. 
Clothing  should  be  changed  at  need,  in  spite  of  the  protests  of  old 
women;  and  there  is  never  so  much  need  of  a  daily  sponge  bath  as 
during  the  menstrual  time.  The  salutary  truth,  that  filth  and  health 
do  not  agree,  should  be  pressed  upon  the  young  girl  and  upon  the 
older  woman  who  complains  of  an  ill-smelling  menstrual  discharge 
when,  in  fact,  she  is  offensive  from  the  rancidity  and  putrescence  of 
axillary  secretions.  The  fishermen's  wives  in  Europe,  the  bathing 
attendants  at  the  seashore,  and  the  patients  at  water-cure  establish- 
ments are  not,  in  general,  permitted  to  abstain  from  contact  with 
water  at  the  menstrual  time,  and  they  are  not  aware  of  any  great 
harm  resulting  from  the  exposure. 

In  the  early  stages  of  Eaynaud's  disease,  Basedow's  disease,  phthi- 
sis, chlorosis,  and  a  number  of  forms  of  anaemia,  amenorrhoea  is  an 
early  symptom.  In  the  late  stages  of  disease,  the  wretched  female 
patient  often  looks  back  over  her  career  and  recalls  to  memory  some 
one  of  the  traditional  causes  of  suppression — a  bath,  a  drenching,  or 
what  not — and  with  poor  logic  she  connects  the  exposure,  the  sup- 
pression and  her  ruined  health  in  a  causal  chain.  Experience,  the 
fruitful  mother  of  all  error,  has  its  preconceived  theory;  it  marks  the 
hits ;  it  forgets  the  misses ;  it  perpetually  confirms  the  error  with 
which  it  began.  And  so  it  happens  that  the  greater  number  of 
women  are,  at  the  menstrual  time,  fearful  of  harm  when  they  make 
a  toilet  for  the  skin,  or  put  the  hands  in  cold  water,  or  walk,  or  ride, 
or  dance,  or  do  a  thousand  things  which  are  considered  proper  and 
safe  during  the  intermenstrual  period. 


MENSTRUATION  7I3 

The  list  of  complications  which  are  said  to  go  with  menstruation 
is  one  which  might  be  safely  attributed  to  a  group  of  men.  It  in- 
cludes constipation  or  diarrhoea,  subjective  sensations  of  heat  or  cold, 
increase  or  diminution  of  urine,  anorexia  or  craving  appetite,  in- 
creased activity  of  the  sudoriparous  glands,  pigmentation  of  the  skin, 
yawning,  cramping,  hiccough,  meteorism,  palpitation,  and  irritable 
temper ! 

For  a  short  period  at  the  very  height  of  menstruation,  the  bodily 
temperature  is  elevated  about  half  a  degree.  In  very  impressionable 
persons,  this  causes  a  slight  feehng  of  lassitude.  A  certain  slight 
dragging  sensation,  a  feeling  of  weight  in  the  legs,  and  a  definite 
though  slight  pain  in  the  sacrum,  groins,  and  thighs,  often  cause 
menstruating  women  to  take  more  than  their  usual  repose.  It  would 
not  be  wise  to  induce  such  women  to  exercise  violently;  neither,  on 
the  other  hand,  is  it  wise  to  coddle  them  and  cultivate  valetudi- 
narianism. 


CHAPTER  XLVI 

THE  DISORDERS   OF   MENSTRTJATION 

Menorrhagia,  general  systemic  causes,  local  causative  diseases  above  the  pelvis, 
pelvic  causes ;  treatment — Metrorrhagia — Amenorrhcea ;  treatment — Retention 
of  menses,  symptoms  and  diagnosis ;  treatment — Dysmenorrhoea ;  treatment — 
Membranous  dysmenorrhoea — Intermenstrual  pain — Vicarious  menstruation — 
The  menopause. 

Menorrhagia. — j\Ienorrhagia  is  an  excessive  flow  from  the  uterus 
at  the  menstrual  time.  Only  its  periodicity  distinguishes  it  from 
metrorrhagia. 

We  can  hardly  conceive  of  hemophilia  as  a  cause  of  menorrhagia. 
Women  transmit  this  defect  of  constitution,  but  the  disease  is  so  mani- 
festly incompatible  with  menstruation  that  Nature  has  long  since 
stamped  out  the  tendency  to  hemophilia  in  the  female. 

General  Systemic  Causes. — (a)  In  purpuric  conditions  we  have  a 
strong  tendency  toward  menorrhagia,  for  in  this  disease  the  blood  is 
altered  in  such  wise  that  it  has  a  manifest  tendency  to  transudation,  and 
a  loss  of  its  normal  coagulability.  Menstruation  opens  the  door  and 
the  flow  is  excessive,  (b)  In  all  forms  of  anwmia  we  have  a  relatively 
great  amount  of  water  in  the  blood,  a  relatively  diminished  amount  of 
albuminoid  substances,  and  diminished  coagulability.  Chlorosis,  in 
this  regard  as  in  many  others,  stands  apart  from  the  anaemias,  for  it 
tends  to  scant}^  flow,  if  any.  (c)  In  plethora  the  increased  flow  is  due 
to  high  arterial  tension  rather  than  to  a  morbid  condition  of  the  blood. 
{d)  In  the  different  chronic  forms  of  nephritis  we  have  an  altered  condi- 
tion first,  of  the  blood,  and,  later,  of  the  blood  vessels,  both  disposing  to 
hemorrhage,  (e)  In  malarial  poisoning  we  have  the  bleeding  tendency 
well  marked,  not  alone  in  the  uterus,  but  also  in  the  rectum,  bladder, 
and  nose.  (/)  In  any  form  of  debility,  menstruation  is  apt  to  run  into 
excessive  hemorrhage  from  inability  to  promptly  repair  the  endome- 
trium, (g)  In  the  specific  infectious  diseases  we  have  reason  to  believe 
that  hemorrhage  is  often  excessive  by  a  combination  of  depraved  blood, 
altered  blood  vessels,  and  the  debility  of  an  organism  that  is  too  busy 
with  the  disease  to  make  repairs  in  the  uterus. 

Local  Diseases  above  the  Pelvis,  causing  Menorrhagia. — (a)  Violent 
emotion  has  often  been  known  to  increase  the  menstrual  flow,  even 
to  the  danger  point.  We  are  obliged  to  assume  that  it  causes  vasomotor 
714 


THE  DISORDERS  OF   MENSTRUATION  715 

paralysis,  (b)  In  cardiac  disease  with  venous  stasis,  extravasation  is 
invited.  Stagnant  blood,  dammed  back  in  the  veins  by  an  inefficient 
heart,  seeks  a  place  of  least  resistance  even  in  the  male  patient.  In 
the  female  the  place  is  indicated  plainly,  once  a  month,  (c)  Pulmonary 
disease  may  run  such  a  course  as  to  obstruct  the  pulmonary  circulation 
early,  thus  wearing  out  the  right  heart  and  leading  to  venous  stasis. 
Ordinarily,  the  early  course  of  the  disease  is  toward  amenorrhoea,  or 
scanty  menstruation,  and  the  blood  is  rich  in  the  coagulating  prin- 
ciple, (d)  In  hepatic  disease,  the  return  of  blood  from  the  uterus  is 
impeded,  and  there  exists  in  jaundice  the  hemorrhagic  tendency  which 
is  the  plague  of  the  surgeons,  (e)  In  splenic  disease,  also,  there  is 
some  obscure  alteration  of  blood  or  of  blood  vessels  disposing  to  hemor- 
rhage as  in  urtemia.  All  these  causes  of  menorrhagia  are  rare,  how- 
ever, (f)  In  a  given  number  of  cases  of  abdominal  tumour  we  shall 
find  a  great  number  of  cases  of  menorrhagia  due  to  pressure  of  the 
great  venous  avenues  of  return  of  blood  and  to  the  perturbing  influence 
of  pressure  on  the  uterus,  {g)  Yet,  the  commonest  cause  of  menor- 
rhagia, after  all,  is  the  f cecal  tumour  so  often  present  in  the  female 
patient.  It,  like  any  other  abdominal  tumour  of  its  size,  operates 
viciously  by  compressing  venous  trunks;  it  presses  upon  the  uterus 
and  directly  irritates  the  organ;  it  is  liable,  through  the  sympathetic 
system,  to  irritate  the  nervous  apparatus  of  the  uterus  and  increase  its 
arterial  supply;  by  its  downward  pressure  it  aggravates  every  flexion 
and  version;  it  slowly  establishes  a  condition  of  stercorsemia  and 
hydrgemia;  it  breeds  a  tympanitic  tumour  in  addition  to  the  solid 
fgecal  mass,  and  thus  still  more  increases  pressure. 

Pelvic  Causes  of  Menorrhagia. — But  for  the  etiology  of  menor- 
rhagia, we  look  most  to  the  bleeding  organ  itself  and  to  its  neighbours 
in  the  pelvis.  The  uterus  and  tubes  are  anatomically  continuous  and 
virtually  inseparable  by  dissection.  These  organs  and  the  ovaries  have 
a  common  nervous  supply.  The  whole  trio  is  fed  by  only  two  pairs 
of  arteries,  and  their  veins  are  few  and  simple.  It  is,  therefore,  in- 
herently probable,  and  it  is  clinically  proved,  that  irritation  or  inflam- 
mation of  one  of  these  organs  must  lead  to  exalted  function  of  the 
other  two. 

Passing  to  the  uterus  itself,  we  note  that  one  of  the  most  com- 
mon causes  of  menorrhagia  may  be  found  in  the  subinvolution  of  the 
uterus  after  abortion.  Subinvolution  may  also  occur  after  delivery  at 
full  term,  especially  if  it  is  not  followed  by  lactation. 

In  the  condition  known  as  areolar  hyperplasia,  sometimes  reck- 
oned a  true  chronic  corporeal  metritis,  we  have  a  flabby,  atonic  state 
of  the  uterus  with  enough  inflammation  to  determine  much  blood 
to  tlie  uterus  and  to  limit  its  power  of  repair  after  the  menstrual 
wreck. 

Inflamrrialion  involving  the  endom.elrium,  tends  to  produce  menor- 
rhagia, and  this  tendency  is  especially  well  marked  in  the  cases  where 
large  granulations  ai'o  pi-odueod  on  tli(!  interioi-  surnice. 


716  A  TEXT-BOOK   OF   GYNECOLOGY 

Healed  lacerations  of  the  cervix  and  deep  ulcerations  at  the  same  site 
sometimes  seem  to  be  starting-points  for  an  irritation  that  disposes  to 
an  increase  of  menstrual  blood. 

In  malpositions  of  the  uterus  we  have  often  the  greatest  irritation 
leading  to  increased  blood  supply.  In  some  of  the  malpositions,  the 
veins  of  the  broad  ligament  become  varicose  from  distortion  and  long- 
continued  pressure.  The  blood  returning  from  the  small  vessels  of  the 
endometrium  passes  into  the  uterine  sinuses  and  thence  toward  the 
heart  by  way  of  the  veins  in  the  pampiniform  plexus,  and  it  is  evident 
that  any  limitation  of  the  carrying  power  of  the  veins  of  this  plexus 
will  produce  some  degree  of  stasis  in  the  uterus. 

Uterine  tumours  also  act  in  this  double  manner  to  cause  menor- 
rhagia;  they  vastly  increase  the  normal  irritation  of  the  uterus,  and 
they  act  in  a  mechanical  manner,  by  pressure  or  by  dragging,  to  block 
the  veins  of  the  broad  ligament.  Subperitoneal  tumours  do  less  harm 
than  those  which  lie  in  the  wall  of,  or  under,  the  endometrium.  After 
incomplete  abortion,  when  some  portion  of  placental  tissue  remains 
rooted  in  the  endometrium,  the  menstrual  flow  is  sometimes  enormous. 
The  irritation  is  out  of  all  proportion  to  the  size  of  the  offending 
body.  Malignant  disease  of  the  uterus  often  leads  to  menorrhagia 
at  an  early  stage.  Sometimes  the  menorrhagia  has  no  provoking  cause 
that  can  be  detected.  The  theory  of  congestion  is  then  invoked  to 
cover  our  ignorance.  Reinecke  and  others  have,  of  late  years,  devel- 
oped the  fact  that  in  some  cases  of  menorrhagia  the  uterine  arteries 
are  sclerosed,  prematurely  old,  prominent,  and  incapable  of  contraction. 
They  carry  a  maximum  of  blood  and  necessarily  tend  to  menorrhagia. 

Treatment  of  Menorrhagia, — When  menorrhagia  is  due  to  plethora, 
the  tendency  is  toward  automatic  palliation.  Later,  the  volume  of  the 
blood  may  be  diminished  by  purgatives,  exercise,  and  restricted  diet. 

In  all  forms  of  hydrsemia,  the  treatment  must  look  to  restoring  to 
the  blood  its  nutrient  principles  and  especially  its  saving  power  of 
coagulation.  In  the  very  time  of  menstruation,  every  means  of  limiting 
the  discharge  should  be  used;  for  each  hemorrhage,  by  impoverishing 
the  blood,  invites  a  more  profuse  and  prolonged  hemorrhage.  The 
bowels  should  be  kept  open  without  violent  purgation.  The  subject 
should  lie  rather  than  sit.  The  feet  should  be  warm,  day  and  night. 
In  urgent  cases  the  tampon  should  be  applied  in  such  a  manner  as  to 
correct  any  malposition  of  the  uterus,  and  it  should  make  firm  pressure 
on  the  cervical  tissues.  Since  it  is  not  the  object  to  coagulate  the 
blood  in  the  vagina,  no  styptic  substance  should  be  used.  The  tampon 
should  rather  be  treated  with  some  antiseptic  substance  like  boric  acid 
which  is  only  slightly  toxic,  is  inofi^ensive,  and  has  a  faint  acid  reaction, 
to  avoid  neutralizing  the  normal  acids  of  the  vagina.  In  extreme 
emergencies  the  uterus  might  well  be  flushed  with  hot  water  at  110°  to 
115°  F.,  under  asepsis  and  with  free  return  of  fluid  secured.  The 
emergency  passed,  the  attempt  should  be  made  to  improve  general  nu- 
trition and  to  enrich  the  blood.     The  milder,  scale  preparations  of 


THE   DISORDERS  OP  MENSTRUATION  Yl7 

iron  have  great  value  for  prolonged  use.  In  the  presence  of  a  brisk 
hemorrhage,  the  tincture  of  the  chloride  of  iron  is  of  most  value.  The 
common  impression  that  iron  increases  an  existing  hemorrhage  has  no 
basis  in  fact.  Arsenic  is  of  great  value  in  anaemia,  and  may  well  be 
alternated  with  iron. 

The  debility  which  leads  to  menorrhagia  is  often  based  on  some 
hemic  defect.  It  will  often  demand  a  blood  count  and  estimate  of 
hemoglobin  with  a  study  of  excreta  for  a  comprehension  of  its  causes. 

Meno]'rhagia  complicating  the  acute  infectious  diseases  is  seldom 
severe  or  long  continued.  In  the  exanthemata,  it  usually  declines  with 
the  develoj)ment  of  the  cutaneous  eruption.  In  scorbutus,  treatment 
must  be  addressed  chiefly  to  the  imderlying  disease,  and  that  treat- 
ment is  dietetic.  In  menorrhagia  resulting  from  nephritis,  the 
treatment  must  reach  the  underlying  disease,  also.  In  malarial  cases, 
treatment  for  the  toxsemia  will  accomplish  brilliant  results  even  in  an 
emergency.  The  chief  danger  in  menorrhagia  is  that  the  physician  will, 
with  mind  prepossessed,  seek  for  a  cause  in  the  pelvic  organs  and 
overlook  some  profound  disease  or  dyscrasia.  Menorrhagia  caused  by 
great  disturbance  of  the  emotions  should  be  treated  by  palliative  meas- 
ures at  first.  The  menorrhagia,  curiously  enough,  tends  to  repeat  itself 
for  a  few  months.  When  this  affection  is  a  result  of  cardiac  or  of  pul- 
monary disease,  it  needs  virtually  no  treatment  save  that  which  is 
directed  to  the  relief  of  venous  stasis.  In  pulmonary  disease,  the  ulti- 
mate tendency  to  amenorrhcea  will  be  an  aid.  When  menorrhagia  com- 
plicates hepatic,  splenic,  or  renal  disease,  the  treatment  is  mostly  pal- 
liative, while  the  fight  is  made  upon  the  causal  disease.  In  advanced 
stages,  when  a  cachexia  has  been  established,  menorrhagia  is  rarely  a 
complication.  The  treatment  of  abdominal  tumours  is  a  matter  of  sur- 
gery, not  to  be  considered  in  this  chapter.  The  treatment  of  fsecal 
tumours  is  of  the  greatest  importance  and  may  be  here  discussed.  They 
should  be  swept  out  by  repeated  doses  of  purgatives.  In  severe  cases, 
it  may  be  necessary  to  aid  purgatives  by  enemata  or  by  tunnelling 
through  hard  masses  in  the  rectum.  If  it  is  known  that  there  is  no 
obstruction,  calomel  may  be  given  in  an  efficient  dose  combined  with 
podophyllin,  or  any  of  the  more  powerful  vegetable  purgatives.  For 
initial  purging,  the  salines  may  suffice.  They  have  a  special  value  in 
their  power  to  cause  a  free  osmosis  into  the  intestinal  tube,  reducing 
incipient  inflammation  and  putting  an  end  to  the  absorption  of  poisons 
from  the  intestine  into  the  blood.  Eepeated  enemata,  each  measuring 
half  a  pint,  of  a  saturated  solution  of  magnesium  sulphate,  retained 
as  long  as  possible,  will  often  produce  great  results  and  save  the  patient 
the  annoyance  of  large  and  repeated  doses  of  medicine  per  os.  When  the 
bowel  is  well  emptied,  it  is  important  to  keep  it  empty  to  the  physio- 
logical limit.  liadical  and  abrupt  changes  in  diet  will  have  some  effect, 
but  very  little,  in  tlie  average  woman  of  constipated  habit.  The  laxa- 
tive power  of  fruit  is  a  fiction  from  Paradise.  So  long  as  it  is  a 
novelty,  oatmeal  is  sometimes  an  (ifficient  laxative,  but  the  system  is 


718  A  TEXT-BOOK   OP   GYNECOLOGY 

soon  habituated  to  it.  Mustard  seed  or  flaxseed,  swallowed  without 
mastication,  is  oftentimes  very  efficient.  Senna,  the  basis  of  most  of 
the  secret  purgative  and  laxative  teas  and  syrups,  is  to  be  commended 
in  small  doses  for  a  limited  time.  As  an  alternate  medicine,  cascara 
sagrada  is  most  excellent.  The  intestines  rarely  become  habituated  to 
this  medicine.  Atropine  and  strychnine  seem  to  have  some  effect  in 
breaking  up  constipation. 

It  has  long  been  taught  that  a  sharp  purgative,  preferably  a  mer- 
curial, given  a  short  time  before  menstruation,  has  a  distinctly  cura- 
tive effect  in  some  cases.  The  treatment  should  be  kept  up  for  some 
months.  It  may  be  conceived  that  the  benefit  is  accomplished  by  de- 
pleting pelvic  viscera,  diminishing  a  mild  metritis,  and  exercising  a 
tonic  nervous  action  on  the  uterine  blood  vessels. 

Supposing  the  bowels  to  be  in  good  order,  one  may  resort  to  ergot 
and  its  allies,  ustilago  and  gossypium,  with  a  hope  of  permanently  con- 
tracting the  fibres  of  the  uterus  and  the  muscular  fibres  of  uterine  and 
ovarian  arteries.  The  liquid  preparations  of  these  drugs  are  so  bulky 
and  offensive  that  tablets  of  ergotin  are  to  be  preferred.  The  treatment 
is  of  no  avail  in  emergencies,  but  under  ordinary  circumstances  should 
be  maintained  for  one  or  two  months  at  least. 

Excellent  results  will  sometimes  be  attained  by  giving  potassium 
iodide  for  ten  or  twelve  days  previous  to  the  menstrual  time.  The 
dose  should  rise,  as  rapidly  as  tolerance  will  permit,  from  10  to  40 
grains  per  diem,  and  be  there  maintained  until  the  second  day  of 
menstruation.  Apart  from  any  obscure  "  alterant "  action,  the  drug 
produces  its  benefits  through  known  channels.  It  has  a  power  of 
dilating  systemic  arteries  and  lowering  arterial  tension;  it  improves 
the  nutrition  of  the  heart,  in  many  eases,  by  its  direct  action  on 
heart  muscle  and  by  its  action  on  the  coronary  arteries;  it  cures  bron- 
chitis and  bronchitic  asthma  and  moderates  the  complications  of  em- 
physema, thereby  lightening  the  labours  of  the  right  side  of  the  heart 
and  diminishing  venous  stasis;  it  palliates  concealed  syphilis.  For 
prompt  and  evanescent  action  as  artery  dilators,  alcohol  and  the  nitrites 
may  be  used.  Digitalis  has  no  place  in  the  routine  treatment  of  menor- 
rhagia.  It  is  only  indicated  in  cases  where  the  hemorrhage  is  caused  by 
some  cardiac  disease  demanding  the  drug. 

The  use  of  styptic  substances  per  os  has  no  other  justification  than 
a  credulous  hope  that  the  stomach  may  be  induced  to  take  up  so  much 
of  the  drug  that  the  blood  will  be  saturated  to  a  degree  sufficient  to 
check  undue  hemorrhage  at  a  distant  point.  Quinine,  strychnine,  and 
atropine,  have  no  direct  effect  upon  the  hemorrhage,  but  have  great 
value  when  it  is  desired  to  whip  up  circulatory  or  respiratory  centres, 
or  the  lumbar  centres  which  send  fibres  through  the  hypogastric  plexus 
to  the  uterus  and  its  appendages. 

In  rare  cases,  supposed  to  be  caused  by  ovarian  irritation,  the  bro- 
mides will  diminish  the  menstrual  flow.  They  certainly  tend  in  the 
main  to  diminish  the  flow,  and,  as  Ernst,  of  Vienna,  has  pointed  out. 


THE   DISORDERS  OP   MENSTRUATION  71<> 

to  increase  the  interval  between  menstrual  periods.  Whether,  for  the 
benefit  reached,  it  is  well  to  blanket  the  whole  nervous  system  with  a 
depressant  drug,  is  a  question. 

Electricity  has  doubtless  a  place  in  the  treatment  of  menorrhagia, 
though  it  will  be  the  resource  of  the  few.  The  positive  pole  in  the 
uterus,  carrying  a  galvanic  current  has  an  admitted  hemostatic  effect, 
the  current  being  cautiously  raised  to  from  30  to  50  milliamperes. 
Later,  in  the  absence  of  hemorrhage  or  inflammation,  the  current  may 
be  much  increased.  In  any  case,  a  cure  can  not  be  expected  under  a 
treatment  extending  over  months.  In  emergencies,  the  current  used  in 
the  interior  for  hemostasis  may  be  raised  to  150  milliamperes,  and  it 
must  be  understood  that  it  is  then  positively  cauterant.  Strict  anti- 
septic technique  must  accompany  this  treatment.  (Goelet,  New  York 
Medical  Record,  March  28,  1891.) 

Desperate  cases  of  menorrhagia  may  require  the  induction  of  the 
artificial  menopause  by  the  aid  of  the  surgeon. 

Metrorrhagia. — Metrorrhagia  is  a  hemorrhage  from  the  uterus  in 
the  intermenstrual  period.  Time  was  when  menorrhagia  and  metror- 
rhagia were  a  long  way  apart,  but  it  is  now  perceived  that  all  red  fluxes 
from  the  uterus  are  essentially  hemorrhages,  and  all  akin.  When  we 
meet  with  a  metrorrhagia  which  begins  in  an  intermenstrual  period, 
continues  with  increased  volume  through  a  menstrual  period,  and  so 
runs  on  for  weeks,  we  perceive  small  difference  between  the  two  affec- 
tions; or,  if  we  encounter  a  case  of  sharp  menorrhagia  which  each 
month  lingers  longer  through  the  intermenstrual  period  to  become 
at  last  an  unbroken  flow,  we  must  admit  that  our  classification  is 
artificial  and  a  matter  of  mere  words.  The  reader  is,  therefore,  referred 
to  the  preceding  section  for  the  causes  of  metrorrhagia  in  general,  since 
these  uterine  hemorrhages  are  not  sharply  distinguished  in  their 
etiology. 

Metrorrhagia  in  early  life  almost  always  points  to  anaemia,  and 
particularly  that  anaemia  which  is  very  properly  referred  to  sterco- 
rsemia. 

In  young  married  women,  metrorrhagia  should  excite  suspicion  of 
incomplete  abortion.  In  such  cases  curettage  should  be  done  after  the 
technique  laid  down  in  another  part  of  this  work.  The  mechanical 
removal  of  the  wreckage  of  an  incomplete  abortion  has  the  added  ad- 
vantage that  it  gives  opportunity  to  remove  the  dilated  follicles  that 
maintain  uterine  hemorrhage  in  low  grades  of  endometritis,  whether 
the  endometritis  is  a  result  of  abortion,  or  not.  The  operation  also 
clears  the  diagnosis  by  giving  information  of  intrauterine  tumours. 

In  mature  life,  metrorrhagia,  much  more  than  menorrhagia,  should 
excite  suspicion  of  uterine  cancer.  Such  subjects,  approaching  the 
menopause,  look  complacently  upon  an  intercurrent  flow  as  a  sign  of 
vigour  or  of  plethora.  They  know  that  pain  and  fu3tor  belonp;  to  can- 
cer, and,  having  no  knowledge;  beyond  this,  they  pass,  still  in  good  gen- 
eral health,  beyond  all  possibility  of  surgical  aid.    In  the  present  state 


720  A  TEXT-BOOK   OF   GYNECOLOGY 

of  our  knowledge,  it  would  be  well  if  every  case  of  metrorrhagia  in 
women  past  thirty-five  j^ears  were  held  to  be  a  case  of  cancer  until  the 
contrary  was  proved.  In  the  absence  of  a  visible  and  tangible  mass  of 
malignant  growth,  the  physician  should  still  hold  doubts  as  to  small 
adenomata  of  mucous  glands  of  the  endometrium.  In  2,200  cases  of 
metrorrhagia,  Baer  found  41  who  had  malignant  disease  of  the  uterus. 
Only  3  of  these  were  younger  than  thirty-five  years;  only  5  were  older 
than  fifty-five  years;  26  of  them  fell  in  a  group  in  the  years  between 
forty  and  fifty-five  years  of  age. 

Metrorrhagia  is  sometimes  maintained  by  a  sclerosis  of  arteries, 
as  in  the  case  of  menorrhagia.  Leopold,  in  1896,  made  4  extirpations 
of  the  uterus  in  women  who  had  borne  from  4  to  12  children,  and 
found  the  uterine  arteries  large,  tortuous,  thick,  and  gaping.  The 
vessels  projected  above  a  cut  section.  The  thickening  was  of  the  median 
layers,  the  intima  not  being  afllected.  The  extirpations  were  made  for 
suspected  malignant  neoplasm.  Curetting  had  been  of  no  avail  and 
ergot  had  appeared  to  increase  the  hemorrhage. 

When  the  floor  of  the  pelvis  has  been  broken  down,  with  great 
damage  to  the  levatores  ani  and  to  the  recto-vesical  fascia,  metror- 
rhagia is  likely  to  follow  in  the  course  of  years,  and  to  be  so  intractable 
that  surgical  treatment  only  will  avail. 

The  general  principles  of  treatment  laid  down  for  menorrhagia 
apply  here.  In  metrorrhagia,  intrauterine  applications  will  work  a 
cure  in  a  larger  proportion  of  cases  than  in  menorrhagia.  The  cervix 
being  sufficiently  dilated,  iodine  in  solution;  phenol,  pure,  diluted,  or 
combined  with  iodine;  creosote  in  solution;  or  tannic  acid,  may  be 
carried  up  to  treat  the  entire  endometrium  with  the  hope  of  diminishing 
succulence  or  atony,  or  of  reducing  inflammation.  The  solution  of 
these  and  other  styptic  and  cauterant  substances  is  often  made  in 
glycerine,  and  that  solvent,  by  virtue  of  its  great  avidity  for  water,  is 
able  to  deplete  the  endometrial  tissues  and  new  growths. 

Amenorrhoea. — Amenorrhoea  is  not  a  definite  disease  or  even,  in  all 
cases,  a  symptom  of  disease.  By  the  term  is  indicated  merely  an  ab- 
sence of  menstruation.  Amenorrhoea  may  be  physiologic,  as  in  nursing 
women  and  in  pregnant  women,  or  it  may  be  symptomatic  of  some 
wasting  disease. 

An  interesting  group  of  women  appear  to  be  perfect  in  their  devel- 
opment and  yet  never  menstruate.  Not  all  such  women  are  sterile, 
though  conception  is  excessively  rare  among  them.  Millikin  has  knowl- 
edge of  one  such  case,  a  woman  who  has  been  happily  married  for 
twenty  years.  Hubbard  Winslow  Mitchell  {Neiv  York  Medical  Record, 
March,  1892)  reports  an  Irish  immigrant,  well  developed  as  to  geni- 
talia and  breasts,  who  had  never  menstruated.  Withrow,  of  Cin- 
cinnati, has  reported  the  cases  of  two  sisters,  and  the  daughter  of 
another  sister,  who  had  never  menstruated.  All  three  of  them  had  en- 
joyed the  sexual  relation  and  all  were  sterile.  Two  of  them  had  profuse 
periodical  epistaxis. 


THE   DISORDERS  OF   MENSTRUATION  721 

It  would  appear  that  this  condition  of  amenorrhoea  may  be  acquired, 
■as  in  the  notable  case  reported  by  Petit  {Annales  de  gynecologie,  1883), 
in  which  the  woman  of  twenty-one  years  was  found  with  a  child  be- 
tween her  thighs,  an  inverted  uterus  and  an  adherent  placenta.  Eeduc- 
tion  was  accomplished,  and,  after  a  tedious  convalescence,  she  was 
restored  to  health  in  the  course  of  eighteen  months.  Although  she 
bore  a  child  after  two  years  and  a  half,  another  in  sixteen  months,  and 
her  fourth  child  after  six  years,  she  never  menstruated  and  never  had 
leucorrhoea. 

In  most  cases  of  lifelong  amenorrhoea  something  teratological  ap- 
pears. Thus,  Walter  B.  Chase  (American  Journal  of  Obstetrics,  Ko.  4, 
1898)  records  the  case  of  a  woman  of  good  physical  development  who 
had  the  menstrual  molimina  every  twenty-eight  days  from  the  age  of 
eighteen;  she  married  at  twenty-two  years  and  came  under  his  notice 
at  twenty-four  years  of  age.  She  had  been  sterile  through  two  years 
of  married  life.  Her  periodical  pain  was  unbearable,  and  insanity  was 
feared.  Her  abdomen  was  very  fat  but  tumour  was  diagnosticated. 
'Operation  revealed  a  thin-walled  sac  subdivided  into  cavities  of  which 
some  were,  and  some  were  not,  infected,  and  a  teratoma  containing 
.sebaceous  matter  in  emulsion,  hair  plates,  and  bone.  Ko  Fallopian 
tubes  were  found.  A  small  amount  of  ovarian  tissue  was  flattened  on 
the  wall  of  the  multilocular  cyst,  with  an  imperfect  corpus  luteum. 
Manton  reports  (American  Gynecological  Journal,  March,  1891)  a 
woman  of  twenty-two,  married  three  years,  who  had  never  menstruated, 
but  for  four  or  five  years  had  suffered,  periodically,  with  abdominal 
cramps,  severe  headache,  and,  occasionally,  tender  and  swollen  breasts. 
,She  had  no  vagina,  but  the  husband's  perseverance  had  made,  at  the 
fossa  navicularis,  a  pouch  3^  inches  deep,  leading  nowhere.  Eectal 
examination  with  a  sound  in  the  bladder  showed  the  ovaries  in  proper 
position,  but  no  uterus  could  be  found.  Manton  has  seen  a  girl  in  a 
similar  condition.  She  seemed  to  enjoy  such  "  intercourse  "  as  was 
possible  to  one  who,  in  lieu  of  a  vagina,  had  a  cul-de-sac  of  a  depth  of 
only  2  inches.  Herbert  C.  Jones,  of  Decatur,  111.,  gives  an  account  of 
a  woman  of  size  and  stature  above  the  average,  who  consulted  him  as 
to  a  vaginal  discharge.  She  had  never  menstruated.  He  found  that 
she  had  a  capacious  vagina,  a  large,  hooded  clitoris,  a  uterus  three  quar- 
ters of  an  inch  in  depth,  and  no  ovaries  to  be  distinctly  palpated.  She 
had  no  mammae,  and  her  nipples  were  rudimentary.  Her  statement 
that  sexual  intercourse  gave  great  pleasure  was  confirmed  in  a  day  or 
two  when  it  was  determined  that  her  discharge  was  from  gonorrhoea 
contracted  the  second  year  after  marriage  through  illicit  intercourse. 

In  young  girls,  there  is  often  a  period  of  amenorrhoea  following 
hard  upon  the  first  one,  two,  or  three,  menstrual  periods.  In  most 
■cases  this  failure  is  due  to  anemia. 

Treatment  of  Amenorrhoea. — Since  amenorrhoea  is  only  a  symptom, 
it  can  not  in  strictness  be  said  to  require  any  treatment.  The  treatment 
should  be  addressed  to  the  diseases  or  dyscrasia;  of  which  it  is  sympto- 
47 


722  ^  TEXT-BOOK   OF  GYNECOLOGY 

matic.  The  amenorrhoea  which  comes  to  many  young  girls  soon  after 
menstruation  announces  itself,  should  not  be  meddled  with.  It  is  a 
confession  that  Nature^s  first  attempts  were  premature.  The  amenor- 
rhoea of  some  young  girls  is,  however,  a  danger  signal  hung  out  to 
give  warning  of  the  earliest  stage  of  phthisis.  The  treatment  of  the 
symptom  is  wholly  included  in  the  appropriate  treatment  of  the  disease. 

Aneemia  should  also  be  suspected  in  well-grown  girls  who  have 
passed  the  usual  age  of  menstruation.  Most  cases  will  be  found  to  have 
dyspepsia  as  the  underlying  condition,  and  the  dyspepsia  will  gener- 
ally depend  upon  physical  inaction,  incessant  nibbling  without  real 
meals,  addiction  to  sugar,  which,  valuable  as  it  is,  will  destroy  the 
appetite  and  lead  to  fermentative  dj^spepsia  as  girls  use  it  and  abuse 
it.  Cofi^ee  toping  is  a  common  cause  of  dyspepsia  at  this  age.  Whim- 
sical appetites  for  ice,  uncooked  rice,  laundry  starch,  uncooked  prunes,, 
and  miscellaneous  rubbish  may  often  be  detected  by  adroit  questioning, 
and  it  will  be  found  that  these  substances  in  many  cases,  not  only  dis- 
place the  regular  meals,  but  lead  to  a  positive  gastritis,  the  pains 
whereof  are  interpreted  as  an  all-day  hunger  to  be  satisfied  only  by 
the  trash  that  bred  it.  The  subjects  of  these  whims  are  often  fine, 
strong  girls,  who  will  do  well  if  they  can  be  brought  to  take  no  food 
save  at  regular  meals  with  limitations  as  to  cofi^ee,  sweets,  and  raw 
fruits.  An  astonishing  number  of  girls  are  ignorant  of  the  fact  that 
the  human  stomach  needs  long  periods  of  profound  rest;  the  truth 
once  presented  to  them  by  authority,  they  will  often  take  the  reform  in 
their  own  hands  with  honesty  and  enthusiasm. 

Constipation,  or  coprostasis,  which  in  the  older  woman  is  some- 
times the  source  of  uterine  hemorrhage,  in  the  young  girl  very  fre- 
quently produces  such  a  degree  of  anamia  as  to  suppress  the  menses. 
Many  young  girls  are  so  loaded  with  faecal  products  that  the  breath  has 
the  odour  of  a  night-cart.  Here  again,  ignorance  combines  with  lazi- 
ness or  modesty  to  aggravate  the  condition.  It  is  very  easy  to  convince 
the  average  girl  that  it  is  a  filthy  and  degrading  deed  to  go  about  loaded 
with  some  pounds  of  excrement,  and  when  that  is  done  the  case  is  half 
cured.  Purgatives  are  not  indicated  in  these  cases.  The  formation 
of  the  syringe  habit  and  the  absolute  annihilation  of  the  rectal  con- 
science is  most  deplorable.  A  course  of  laxatives,  of  which  cascara  is 
usually  the  best,  combined  with  deep  massage,  rational  physical  exer- 
cise, and  an  immediate  response  to  the  rectal  call,  will  not  only  get 
the  bowel  empty,  but  will  go  far  to  establish  the  habit  of  a  daily 
evacuation  of  the  bowels.  Until  the  stercorsemia  has  been  corrected, 
one  need  not  attempt  to  correct  other  causes  of  anasmia;  when  the 
bowels  have  been  unloaded,  and  when  the  digestion  has  been  amended, 
one  should  settle  the  question  of  the  existence  of  albuminuria,  malaria, 
syphilis,  saturnism,  splenic  disease,  or  whatever  dyscrasia  may  pro- 
duce angsmia  in  young  subjects.  Wlien  all  cases  have  been  sifted, 
there  will  remain  a  residue  of  girls,  and  boys  are  not  exempt,  who,  with- 
out apparent  cause,  develop  the  "  anaemia  of  adolescence." 


THE  DISORDERS  OP   MENSTRUATION  Y23 

For  the  medical  treatment  of  this  anaemia,  the  whole  range  of 
hematinic  drugs  may  be  invoked.  Iron  and  arsenic  are  the  chief  of 
them.  Manganese  has  acquired  a  reputation  probably  far  beyond  its 
deserts. 

Apiol,  an  amber  fluid  obtained  from  parsley  seeds,  has  been  highly 
extolled  by  the  French  as  being  able  to  produce  the  menstrual  flow. 
It  is  given  in  doses  of  from  half  a  gramme  to  a  gramme  and  is  said 
to  be  wholly  innocuous.  The  use  of  oxalic  acid  in  half-grain  doses, 
given  every  four  hours  to  three  doses,  is  said  to  be  very  efficient  as  an 
emmenagogue,  but  it  is  admitted  that  toxic  effects  have  followed  such 
treatment.  All  emmenagogues  are  open  to  an  objection  that  they 
merely  solicit  a  flow  which  ought  not  to  be  directly  solicited,  and 
which  is  sure  to  appear  when  the  physiologic  conditions  of  men- 
struation are  present.  This  objection  applies  to  the  old  and  popular 
terebinthinate  emmenagogues,  and  to  those  composed  chiefly  of  essen- 
tial oils. 

It  should,  indeed,  be  a  general  principle  of  treatment  that  it  is  not 
worth  while  to  bring  on  the  menses,  but  rather  to  annul,  if  possible, 
the  morbid  conditions  under  which  they  disappeared.  We  have  already 
noted  the  fact  that  there  is  a  tendency  toward  amenorrhoea  in  the 
presence  of  any  notable  hardship,  and  we  shall  be  consulted,  perhaps, 
when  that  hardship  has  passed  away.  Even  a  mere  change  that  does 
not  involve  hardship,  will  sometimes  produce  amenorrhoea,  as  when  a 
girl  leaves  the  country  and  enters  a  factory,  or  vice  versa.  Curious  cases 
are  sometimes  observed  in  which  amenorrhoea  develops  after  marriage 
and  persists  for  some  months  without  pregnancy;  and  precisely  reverse 
cases  are  observed  in  which  amenorrhoea  comes  with  widowhood. 
These  cases  are  inexplicable  in  the  present  state  of  our  knowledge,  and 
should  not  be  rashly  meddled  with. 

The  same  principle  applies  to  amenorrhoea  developing  in  the  course 
of  exophthalmic  goitre,  Kaynaud's  disease,  myxoedema,  and  in  connec- 
tion with  the  sudden  and  grave  development  of  fat.  If  we  can  amend 
the  disease,  we  are  likely  to  cure  the  amenorrhoea;  if  not,  the  amenor- 
rhoea can  do  no  harm. 

Retention  of  Menses. — In  amenorrhoea  no  menstrual  fluid  is  pro- 
duced. In  retention,  the  fluid  is  formed  but  does  not  manifest  itself 
externally. 

For  this  seclusion  there  can  be  but  one  cause,  viz.,  occlusion  of 
the  genital  canal  at  some  point.  (See  Malformation  of  the  External 
Genital  Organs.)  The  occlusion  may  be  at  the  os  internum,  or  at  the 
hymen,  or  at  any  intermediate  point,  or  at  all  points  at  once. 

When  the  stenosis  or  occlusion  is  congenital  it  may  be  charged  to 
an  arrest  of  development. 

Acquired  stenosis  of  the  vagina  may  be  produced  by  severe  inflam- 
mation after  parturition,  as  in  Battey's  famous  case  in  which  the  entire 
utero-vaginal  canal  was  obliterated.  It  has  also  been  produced  by 
severe  croupous  or  diplitlieriiic  inflammation  witb  destruction  of  epi- 


Y24  A   TEXT-BOOK  OP   GYNECOLOGY 

thelium,  and  by  Nature's  blundering  repair  after  burns  or  destruction 
of  tissue  by  escharotics. 

Clumsy  surgery  has  produced  stenosis  by  amputation  of  the  cervix, 
especially  when  the  amputation  has  been  done  by  cautery.  The  opera- 
tion of  trachelorrhaphy  has  been  so  done  as  to  cause  stenosis  of  the 
cervical  canal. 

One  third  of  all  cases  are  due  to  an  imperforate  hymen,  and,  as  a 
rule,  the  obstruction  is  external  and  vaginal  rather  than  cervical  or 
uterine. 

Symptoms  and  Diagnosis. — Apparent  amenorrhcea,  with  the  men- 
strual molimen  recurring  regularly,  should  excite  suspicion  of  reten- 
tion. The  ordinary  pains  of  menstruation  may  be  much  exaggerated  by 
the  retention,  so  that  the  pelvic  dragging,  aching  thighs,  legs,  and 
sacrum,  the  flushed  face,  headache,  nausea  and  malaise,  will  become 
almost  unendurable. 

The  general  symptoms  of  sepsis  must  be  added  after  a  time. 

Peritonitis  may  arise,  either  as  a  part  of  the  septic  process  or  as 
a  result  of  expression  of  fluid  from  the  Fallopian  tubes.  Eupture  of 
the  tube  has  occurred  in  rare  cases. 

Bulging  of  the  hymen  will  lead  to  a  diagnosis  if  the  obstruction 
is  due  to  an  imperforate  condition  of  that  structure. 

From  the  first,  the  confined  fluid  forms  a  tumour  which,  growing 
monthly,  sooner  or  later  attains  palpable  dimensions.  If  the  fluid  is 
confined  to  the  uterus,  the  mass  will  be  round;  if  a  tube  is  involved, 
the  mass  will  be  asymmetrical. 

Pregnancy  is  not  absolutely  excluded  when  the  hymen  seems  im- 
perforate or  when  the  vagina  is  closed.  But  in  retention,  by  using 
the  bimanual  method,  the  uterus  may  be  found  central,  mobile,  and 
too  small  for  a  pregnancy  which  has  lasted  as  long  as  the  amenor- 
rhcea;   this,  of  course,  tends  to  exclude  pregnancy. 

When  the  vagina  is  not  available,  a  finger  should  be  introduced  into 
the  rectum  and  a  sound  into  the  bladder,  and  in  difficult  cases  of  diag- 
nosis a  finger  has  been  introduced  into  the  bladder  also,  through  a 
dilated  urethra. 

Solid  and  cystic  tumours  arising  from  the  genitalia  are  diagnosti- 
cated by  the  passage  of  the  uterine  sound  and  by  the  history  of  the  case. 

Hematocele  is  diagnosticated  by  a  history  of  rapid  development, 
often  with  pain  and  shock,  and  the  diagnosis  is  confirmed  by  the  passage 
of  a  sound. 

Abdominal  tumours  must  be  considered  and  carefully  excluded  by 
their  location  and  their  appropriate  symptoms. 

The  mass  of  retained  fluid  sometimes  reaches  a  bulk  of  4  or  5 
quarts,  and  by  its  great  mass  is  puzzling. 

Treatment  of  Retention. — The  only  treatment  is  the  evacuation  of 
the  fluid  by  surgical  means.  To  leave  the  patient  alone,  invites  rup- 
ture. If  the  rupture  is  through  the  hymen  it  invites  sepsis.  Eup- 
ture through  a  Fallopian  tube  or  rupture  of  the  uterus  would  be  dis- 


THE   DISORDERS   OF   MENSTRUATION  725 

astrous.  Emmet  is  singular  in  saying  that  in  this  affection  the  uterus 
becomes  thickened  as  in  pregnancy;  most  reporters  have  found  its 
walls  thinned. 

The  patient  to  whom  relief  is  not  given  surgically ;,  suffers  from  pres- 
sure on  pelvic  viscera.  The  disturbance  of  the  general  health  is  very 
great.  The  fluid  can  not  be  absorbed,  but,  on  the  contrary,  its  mass 
continually  grows  greater. 

The  question  of  how  much  fluid  should  be  drawn  off,  has  agitated 
the  surgeons  for  a  long  time.  Emmet,  following  Dupuytren,  drew  it 
all  off  at  once,  and  flushed  all  accessible  genitalia  Vi^ith  hot  water  until 
they  were  cleansed.  It  must  be  remembered  that  the  fluid  has  only 
the  colour  of  blood  and  lacks  its  antiseptic  qualities,  and  that  fact 
alone  seems  to  justify  the  bold  and  complete  operation.  Puncture  of 
the  protruding  hymen  is  a  trifling  operation,  but  the  surgical  tech- 
nique should  be  as  perfectly  aseptic,  and  possibly  antiseptic,  as  in  the 
most  formidable  operations.  One  or  more  points  of  occlusion  in  the 
vagina  may  need  to  be  torn  open.  Extreme  care  will  be  demanded 
in  such  a  dissection,  to  avoid  opening  the  bladder,  rectum,  or  peri- 
toneal cavity.  Natural  lines  must  be  followed,  not  only  to  avoid 
these  accidents,  but  to  leave  the  greatest  possible  amount  of  epi- 
thelium on  the  raw  surfaces.  It  has  been  found  possible  to  make  a 
vagina  where  there  had  been  absolute  atresia,  the  lumen  being  main- 
tained by  the  prolonged  wearing  of  a  glass  or  rubber  plug,  and  preg- 
nancy and  parturition  have  ensued. 

Puncture  or  incision  of  the  external  os,  the  cervical  canal,  or  the 
region  of  the  inner  os,  should  be  done  upon  the  same  guiding  prin- 
ciples. 

In  rare  cases  in  which  there  was  no  uterus,  but  where  fluid  had 
accumulated  from  tubal  menstruation,  Braxton-Hicks  and  Haffner 
removed  tubes  and  ovaries  at  a  single  operation  by  abdominal  section. 

Dysmenorrhoea. — Some  rare  cases  of  dysmenorrhoea,  or  painful  men- 
struation, appear  to  be  a  manifestation  of  a  general  neuralgic  tend- 
ency due  to  general  neurasthenia.  The  very  wide  distribution  of  the 
pain — abdominal,  sacral,  and  crural — suggests  to  the  mind  the  theory 
of  a  general  nerve  storm,  and  it  is  upon  this  theory  we  rest  when  we 
can  find  no  deformity  or  disease  in  the  uterus  or  its  appendages.  We 
recall  the  anatomic  facts  that  the  nerve  supply  of  the  pelvic  genitalia 
of  woman  is  from  the  second,  third,  and  fourth,  sacral  nerves ;  that 
the  sympathetic  fibres  come  from  plexuses  which  are  virtually  branches 
of  the  aortic  plexus,  and  that  the  aortic  plexus  is  virtually  a  derivative 
from  the  semilunar  ganglion  and  renal  plexus  on  each  side.  The 
genitalia  are  therefore  connected  by  no  remote  strands  with  the  cere- 
bro-spinal  system  and  with  all  abdominal  viscera,  so  that  no  great 
perturbation  of  the  nervous  system  can  occur  without  a  disturbance  of 
tlie  genitalia.  For  pelvic  pain  at  a  menstrual  time,  bred  by  starving 
or  irritated  nerves  in  some  remote  part  of  the  nervous  system,  the 
tenn  dysmcnorrhcr'a  is  inappropriate*  for  it  does  not  appear  that  the 


Y26  ^  TEXT-BOOK  OF   GYNECOLOGY 

pain  is  clue  to  menstruation.  Menorrhalgia,  proposed  by  Massey,  is 
commendable  in  that  it  asserts  pain,  and  nothing  more. 

By  far  the  greater  number  of  cases  are  due  to  some  morbid  condi- 
tion of  the  generative  organs.  Turning  to  the  uterus,  we  note,  first, 
that  the  infantile  uterus,  with  a  depth  of  2  inches  or  less,  a  conical 
cervix,  and  a  pinhole  os,  is  often  a  jDainful  uterus  at  the  menstrual 
time.  The  only  explanation  offered  for  dysmenorrhoea  associated 
witli  the  infantile  uterus  is,  that  the  filaments  of  spinal  nerves  im- 
prisoned in  the  embryonic  stroma  of  the  imperfect  endometrium  are 
compressed  during  the  menstrual  congestion  and  subsequent  changes. 

After  pregnancy,  when  the  uterus  normally  shrinks  from  pounds 
to  ounces,  the  involution  sometimes  passes  all  bounds  and  leaves  the 
patient  with  what  is,  to  all  intents  and  purposes,  essentially  an  infan- 
tile uterus,  by  superinvolution.  Here,  again,  we  have  dysmenorrhoea, 
and  are  again  tempted  to  theorize  as  to  the  replacement  of  muscle  by 
fibrous  tissue  and  the  incarceration  of  nerve  endings. 

There  has  long  been  a  tendency  to  ascribe  menstrual  pain  to  the 
pressure  of  fluid  which,  by  reason  of  partial  stenosis  at  the  inner  or 
outer  OS,  or  at  some  point  of  flexure  of  the  uterus,  has  an  imperfect 
exit  from  the  uterus  and  induces  pain  by  hydraulic  pressure.  The 
old  masters  had  high  controversy  on  this  head.  Hewitt  said,  "  The 
large  majority  of  cases  are  really  cases  of  retention."  Sims  said, 
"  There  can  be  no  dysmenorrhoea,  properly  speaking,  if  the  cervical 
canal  be  straight  and  large  enough  to  permit  a  free  passage  of  men- 
strual blood."  The  curative  effects  of  cutting  and  stretching  opera- 
tions and  the  similar  effect  of  parturition  were  held  to  confirm  this 
doctrine.  But,  per  contra,  MattheAvs  Duncan  was  prompt  to  contend 
that  dysmenorrhoea  was  always  neurotic  in  its  origin;  he  pointed  out 
that  the  pin-point  os  was  large  enough,  as  could  be  demonstrated  on 
thousands  of  women ;  he  urged  that,  in  the  absolute  retention  of 
menses,  the  pain  was  no  greater  than  it  was  in  many  eases  of  dysmen- 
orrhoea with  free  exit;  he  held  it  to  be  significant  that  girls  in  their 
first  menstruation  did  not  usually  suffer  much;  he  showed  that  the 
women  who  suffered  most  had  less  flow  than  others ;  he  demanded  an 
explanation  of  the  fact  that  there  was  no  distention  or  sacculation 
above  the  alleged  stenosis.  Others  re-enforced  him,  declaiming  that 
dilatation  of  the  cervical  regions  cured  dysmenorrhoea,  only  because 
the  irritable  fibres  at  that  point  were  destroyed  or  paralyzed  inci- 
dentally during  the  operation  or  during  parturition.  It  was  also 
shown  that  the  uterine  sound  passed  easily  into  the  cavity  during 
menstruation;  that  autopsies  never  showed  stenosis  at  the  site  of  a 
flexion;  that  the  anguish  was  not  extreme  when  in  membranoiis  dys- 
menorrhoea the  membrane  acted  as  a  valve,  temporarily,  and  arrested 
the  flow.  Confirming  this  negative  argument  came  JHandfield-Jones 
who  declared  that  the  os  was  normally  open  during  menstruation,  that 
it  slowly  closed  in  the  next  week  and  was  tightly  closed  in  the  week 
before  menstruation.     He  ascribed  dysmenorrhoea  to  fibroid  thicken- 


THE  DISORDERS  OP   MENSTRUATION  727 

ing,  liypersesthesia,  and  muscular  spasm  at  the  inner  os.  Williams,  of 
CarditI'  {British  Medical  Journal,  October  M,  1897),  extended  these 
views  in  part  to  the  higher  regions  of  the  uterus  and  suggested  that 
the  pain  of  dysmenorrhea  might  be  caused  by  abnormal  contractions 
set  up  by  diseased  mucous  membrane  at  the  site  of  flexure. 

Those  who  hold  out  for  the  obstruction  theory  admit  that  in  flex- 
ion of  the  uterus  there  may  be  no  stenosis  demonstrable  in  the  post- 
mortem specimen,  but  hold  that,  with  the  ante-mortem  thickening  and 
congestion,  there  may  be  a  decided  obstruction  in  life  which  no  au- 
topsy can  reveal.  The  observation  of  Da  Costa  {Obstetrical  Society  of 
Philadelphia,  December  5,  1889),  that  a  flexion  with  a  regular  curve 
rarely  causes  obstruction,  whereas  a  sharp  bend  does  produce  obstruc- 
tion, is  important  in  this  connection. 

Waiving  all  questions  of  the  causal  relation  of  obstruction,  it  must 
be  admitted  that  a  vast  majority  of  cases  of  dysmenorrhoea  are  asso- 
ciated with  anteflexion.  It  is  very  probable  that  this  deformity  is 
caused  chiefly  by  an  arrest  of  development  in  the  anterior  wall  of  the 
uterus,  and  a  portion  of  the  pain  of  menstruation  may  be  due  to 
causes  which  jDroduce  dysmenorrhcea  in  the  infantile,  or  undeveloped, 
uterus. 

Displacements  of  the  uterus  are  associated  with  dysmenorrhoea, 
but  not  so  frequently  as  flexions.  It  is  a  question  whether  the  pain 
is  produced  by  direct  dragging  on  nerves  or  by  an  interference  with 
the  circulation  at  a  critical  time,  or  by  setting  up  inflammation  in  the 
uterus  or  its  appendages  with  adhesions. 

Uterine  tumours  produce  dysmenorrhoea.  The  general  rule  is  that 
the  more  peripheral  tumours,  as  subperitoneal  fibroids,  set  up  less 
disturbance  than  those  which  lie  nearer  the  endometrium. 

Metritis  and  endometritis  are  common  causes  of  dysmenorrhoea. 
In  its  normal  condition,  the  endometrium  is  almost,  if  not  quite,  as 
insensible  as  the  cartilages  and  serous  membranes,  but,  like  these 
structures,  it  becomes  exquisitely  sensitive  when  inflamed.  There  is, 
in  health,  a  certain  sensitiveness  at  the  internal  os,  giving  the 
patient,  usually,  some  uneasiness,  or  exciting  strong  reflexes  when 
the  sound  is  passed  over  this  region;  in  inflammation,  this  sen- 
sitiveness is  exalted  into  a  capacity  for  excruciating  agony  at  a 
touch.  Metritis  and  endometritis  interfere  with  every  step  in  men- 
struation; from  the  beginning  they  cause  pressure  on  pelvic  vessels 
and  nerves;  the  capillaries  in  the  deep  stroma  become  excessively 
congested  and  prematurely  tear  the  epithelium  away;  the  inflamed 
glands  crowd  and  compress  each  other  and  retard  amyloid  or  hyaline 
flegeneration  ;  and  hyperplasia  welds  the  deep  and  superficial  stroma 
beyond  tbe  possibility  of  normal  degeneration  or  regeneration.  With 
all  this  irritation,  we  can  not  doubt  that  the  uterine  ganglia  will 
become  irritated,  setting  up  contractions  of  muscular  fibre  which 
shall  be  either  wholly  abnormal  or  preternatural  as  to  intensity. 
TTandficld-.Toncs  aiifl  oiliors  have  shown  the  probability  that  there  is 


728  A  TEXT-BOOK  OF   GYNECOLOGY 

in  all  cases  of  menstruation  a  certain  initial  dilatation  of  the  inner  os, 
as  at  the  beginning  of  labour  before  pressure  or  active  dilatation  has 
begun;  if  we  grant  this,  we  shall  doubtless  have  the  intermittent 
pains  of  the  softening  process  aggravated  many  fold  by  the  metritis 
or  endometritis. 

The  connection  of  tubal  disease  or  deformity  with  dysnienorrhoea 
is  based  upon  very  strong  probabilities.  The  evidence  is  chiefly  that 
the  tubes  are  muscular;  that  they  have  motor  ganglia  capable  of  causing 
rhythmic  motion  in  the  tubes  even  after  their  severance  from  the 
body;  that  dysmenorrhoea  is  common  among  women  who  have  sal- 
pingitis; that  it  is  intense  when  a  tube  is  obstructed  at  the  uterine 
junction;  that  the  tubes  are  continuous  with  the  uterus  and  have  the 
same  nervous  and  vascular  supply;  and  that  they  participate  actively  in 
normal  menstruation. 

Dysmenorrhoea  from  oophoritis  is  wholly  denied  by  some  who  say 
that  the  pain  is  merely  referred  to  the  ovary  by  the  sufferer,  when,  in 
fact,  it  originates  elsewhere.  Nevertheless,  there  are  very  competent 
observers  who  have  blamed  certain  severe  cases  of  dysmenorrhoea  on 
the  ovary  by  a  process  of  exclusion.  Dysmenorrhoea  is  sometimes 
found  to  be  associated  with  large,  painful,  easily  palpated  ovaries,, 
so  irritable  that  pressure  upon  them  causes  pain  and  nausea. 

The  study  of  chronic  alcoholism  in  the  female  is  sometimes  con- 
firmatory of  the  doctrine  that  inflammation  of  the  ovaries  may  pro- 
duce dysmenorrhoea;  for  dysmenorrhoea  is  often  set  up  in  heavy 
drinkers  as  a  new  symptom  about  the  time  the  ovaries  become  large 
and  tender. 

Treatment . — No  hope  of  relief  for  dysmenorrhoea  caused  by  an 
infantile  uterus  could  be  extended  if  the  uterus  were  not  unique 
among  the  adult  tissues  in  its  marvellous  degeneration  and  regenera- 
tion. It  has  happened  repeatedly  that  that  which  has  been  correctly 
diagnosticated  as  a  shallow,  imperfect,  undeveloped  uterus,  has  be- 
come gravid  and,  mayhap,  after  repeated  abortions,  has  been  able  to 
carry  a  foetus  to  full  term,  and  thereafter,  reconstructed  by  normal  invo- 
lution, has  maintained  its  proper  adult  condition.  Only  a  few  cases 
have  this  fortunate  termination,  and  the  prognosis  is  more  gloomy 
in  cases  of  superinvolution  occurring  in  women  of  somewhat  mature 
years. 

The  surgical  treatment  of  uterine  flexions  is  so  treated  in  an 
appropriate  part  of  this  work,  that  its  discussion  as  curative  of  dys- 
menorrhoea may  be  omitted  here.  But  assuming  that  the  flexions  of 
the  uterus  are  caused  by  defective  development,  one  might  well  look 
to  the  hygiene  of  the  adolescent  girl  as  a  prophylactic  against  the 
deformity.  It  is  not  going  too  far  to  say  that  the  conventionalities 
of  refined  European  and  American  life  directly  tend  to  undeveloped 
genitals  in  the  young  girl.  The  contrast  between  what  is  decent  and 
proper  among  girls  of  our  time  and  tribe,  and  girls  living  under  sav- 
age conditions,  is  very  great.     The  little  children  in  many  tribes  of 


THE   DISORDERS  OF   MENSTRUATION  729 

savages  are  encouraged  to  attempt  and  to  practise  copulation  until 
puberty,  when,  except  among  the  most  degraded,  the  girls  are  with- 
drawn from  such  possibilities.  In  many  Oriental  countries  the  girls 
are  not  only  pledged  in  marriage  in  babyhood,  but  they  are  actually 
delivered  over  to  their  spouses  before  puberty.  This  is  a  very  wide 
usage,  also,  among  savages ;  it  has  been  a  source  of  horror  and  dismay 
to  our  red  men  that  the  girls  sent  to  Government  schools  menstruated 
while  at  school,  and  the  basis  of  this  rage  and  astonishment  is  the 
Indian's  conviction  that  menstruation  at  school  is  a  sure  sign  that  his 
little  children  have  been  debauched ;  for,  so  early  do  Indian  girls  enter 
into  the  marriage  relation,  that,  as  a  rule,  they  do  not  menstruate 
until  some  time  after  they  have  found  a  place  in  the  husband's  lodge. 
Practices  so  repugnant  to  our  notions  of  decency  and  morality  seem 
most  unnatural,  and  yet  they  belong  to  a  state  of  Nature,  and,  what- 
ever may  be  the  decrees  of  fashion  and  civilization,  there  can  be  no 
doubt  that  the  early  sexual  life,  arousing  rather  than  dwarfing  the 
prophetic  sexual  instincts  of  girls,  tends  to  develop  the  uterus.  The 
free  and  licentious  conversation  of  pastoral  life,  and  even  of  agricul- 
tural life,  in  some  countries,  is  doubtless  a  stimulant  in  the  same 
direction,  and  these  stimulants  are  forever  withdrawn  from  our  girls 
in  the  name  of  decency. 

This  must  be  so;  but  the  mischief  wrought  by  the  young  girl's 
dress  is  remediable.  When  her  breasts  begin  to  bud,  the  young  Amer- 
ican girFs  shame  of  them  is  made  a  virtue  by  her  mother,  and  while 
she  cramps  them  up  with  a  long  and  stiff  corset,  she  jams  all  abdom- 
inal viscera  down  toward  the  pelvis  by  the  same  apparatus.  Most 
girls  say,  and  say  truly,  that  the  corset  is  not  very  tight ;  the  mischief 
is  done  even  by  moderate  pressure  at  the  wrong  place  and  in  the 
wrong  direction.  A  short  and  flexible  corset,  loosely  worn,  might  be 
a  beneficent  thing  by  distributing  the  pressure  of  waistbands,  while 
a  long  corset,  stiff  in  front  if  not  elsewhere,  is  a  positive  injury  by 
transmitting  pressure  downward,  by  increasing  constipation,  and  by 
interfering  with  the  circulation  in  the  uterus  and  its  appendages. 

The  circulation  in  the  uterus  seems  to  be  directly  related  to,  and 
connected  with,  that  of  the  lower  extremities.  It  is  the  misfortune 
of  the  American  girl  that  her  legs  are  going  into  a  state  of  disuse 
by  reason  of  perfected  artificial  locomotion  and  elevators.  As  a  mat- 
ter of  uterine  hygiene,  and  as  a  provocative  of  uterine  growth,  she 
should  walk  much.  Lawn  tennis  should  be  cultivated,  and  other 
games  of  the  sort.  Since  it  involves  walking,  one  might  even  say  a 
good  word  for  golf.  The  bicycle  used  without  excess  is  admirable. 
Housework,  with  its  infinite  variety  of  posturing,  is  to  be  com- 
mended. Horticulture,  with  its  carrying  and  stooping  and  rising,  is 
an  ideal  pursuit.  Gymnastics  might  be  scientifically  prescribed  for 
the  legs  and  the  whole  body,  but  there  was  never  yet  a  girl  who,  in 
dreary  solitude,  would  practise  bodily  movements  for  the  sake  of 
exemption  from  vague  and  half-guessed  pains  in  the  far  future,  and. 


^30  A  TEXT-BOOK  OP   GYNECOLOGY 

for  that  reason,  girls'  gymnastics  must  incline  to  games,  witli  some- 
thing of  excitement  and  rivalry  and  the  exhibition  of  personal  prowess. 

Many  girls  have  the  feet  habitually  cold  in  summer,  and  in  winter, 
so  cold  and  numb  as  to  be  beyond  the  perception  of  suffering.  It  is 
very  important  that  this  state  of  arterial  spasm  should  be  broken  up, 
for  it  is,  as  has  been  suggested,  directly  related  to  deficient  blood 
supply  to  the  pelvic  organs. 

When  there  is  a  marked  flexion  with  dysmenorrhcea,  the  flexion 
must  be  dealt  with  on  surgical  principles  laid  down  elsewhere  in  this 
work. 

Stenosis,  when  it  is  believed  to  be  a  cause  of  severe  dysmenorrhcea, 
should  be  dilated.  The  treatment  is  indicated  whether  it  is  held 
that  mere  obstruction  is  the  cause  of  the  menstrual  pain  or  not,  for 
in  the  latter  case  we  have  reason  to  believe  that  the  stretching  pro- 
cess interrupts  unnatural  and  pain-producing  channels  of  nerve  con- 
duction. 

Extending  his  observations  over  2,000  cases  of  marked  dysmenor- 
rhcea, Emmet  found  that  about  75  per  cent  of  them  were  sterile,  and 
in  this  fact  we  find  another  reason  for  dilatation,  for  it  will  often 
happen  that,  after  that  operation  has  been  thoroughly  done,  preg- 
nancy ensues,  and  this,  wbile  a  positive  benefit  incidentally,  tends  to 
the  cure  of  dysmenorrhcea. 

The  choice  Avill  lie  between  gradual  dilatation,  which  requires  no 
angesthesia  and  may  be  done  at  the  consulting  room,  and  rapid  dilata- 
tion, which  faces  all  risks  of  sepsis  and  inflammation  once  for  all.  In 
1893,  Goodell  reported  400  cases  of  rapid  dilatation  with  hot,  antisep- 
tic irrigation  and  gauze  packing,  and  no  untoward  results,  and,  while 
others  have  not  so  enthusiastically  advocated  the  operation,  it  is  con- 
ceded that  it  is  not  a  grave  one. 

In  the  gradual  dilatation  of  tough  strictures,  electricity  is  of  much 
assistance.  A  sound  is  insulated  to  within  2^  inches  of  its  tip  and  is 
passed  into  the  cervix.  When  resistance  is  met  with,  a  current  of  10 
milliamperes  will  often  cause  the  resistance  to  disappear  in  a  few  min- 
utes. The  treatment  is  completed  by  a  current  of  from  20  to  50  milli- 
amperes for  five  minutes  only.  The  sound  will  drop  out  easily  and 
should  be  replaced  by  a  larger  one  at  the  next  sitting.  The  sound  is, 
of  course,  connected  with  the  negative  pole  and  a  clay  electrode  with 
the  positive. 

For  the  treatment  of  flexions  and  strictures  by  the  cutting  opera- 
tions of  Simpson,  Sims,  Dudley  and  Schroder,  and  for  the  modifica- 
tion of  those  operations  the  reader  is  referred  to  the  appropriate 
chapters.  The  treatment  in  all  cases  seeks  to  amend  any  possible 
stricture  and  to  interrupt  the  channels  of  painful  nervous  reflexes. 
Eeference  to  other  parts  of  this  work  is  also  made  for  the  proper 
treatment  of  displacements  of  the  uterus  by  tampon,  pessary,  or  oper- 
ation on  the  ligaments  or  upon  the  floor  of  the  pelvis ;  for  these  surgi- 
cal devices  may  need  to  be  invoked  for  the  relief  of  dysmenorrhcea. 


THE   DISORDERS   OF   MENSTRUATION  Y31 

Like  reference  must  be  made  also  for  the  appropriate  treatment  of 
metritis  and  endometritis. 

The  pain  of  dysmenorrhoea  is  much  relieved  by  drugs  which  are 
not  strictly  anodyne,  but  rather  antispasmodic.  Chloral  and  croton 
chloral  hydrate  will  control  many  cases.  Some  of  the  milder  cases 
of  pure  neuralgic  type  will  yield  to  a  single  sound  sleep  induced  by 
trional  or  sulphonal.  Sulphonal  has  a  specially  powerful  sedative 
action  on  the  lower  portion  of  the  spinal  cord  whence  the  uterus  and 
its  appendages  receive  their  spinal  supply.  Atropine  will  relieve  a 
certain  number  of  cases,  and  seems  to  benefit  those  women  most  who 
never  have  warm  feet  or  a  blush  of  pink  upon  the  general  surface 
of  the  body.  To  be  of  use,  the  drug  should  be  given  in  increasing 
doses  for  five  days  before  menstruation,  and  it  should  be  so  managed 
that  the  face  shall  be  flushed  for  one  or  two  evenings.  Most  unfor- 
tunately, alcohol  has  a  similar  effect  in  like  cases.  As  it  breeds  an 
indifference  to  small  discomforts  it  is  very  seductive  and  should  not 
be  used. 

Amyl  nitrite  may  be  used  with  good  effect  in  cases  where  the 
pain  comes  and  goes  in  waves.  A  few  drops  may  be  poured  on  cotton 
in  a  wide-mouthed  bottle  and  the  patient  permitted  to  inhale  the 
volatilized  drug  from  time  to  time  as  the  pain  demands.  Cannabis 
indica  will  mitigate  the  pain.  Unfortunately,  its  anodyne  effect  is 
rarely  produced  until  the  patient  is  about  to  experience  some  disagree- 
able confusion  as  to  time  and  space.  Gelsemium  is  a  drug  much  more 
available,  yielding  anodjTie  effects  long  before  it  produces  diplopia. 
The  dejDressant  effects  of  the  lyromides,  affecting  the  whole  nervous  sys- 
tem, should  be  borne  in  mind.  In  ordinary  cases,  the  relief  from  pain 
under  the  bromides  is  too  dearly  purchased.  Camphor  yields  surpris- 
ing results  occasionally,  but  is  worthless  in  most  cases. 

Brisk  eliminant  treatment,  with  the  administration  of  salicylates  of 
sodium,  a^nmonium  and  lithium,  will  so  signally  relieve  certain  cases 
as  to  reveal  the  gouty  or  rhemnatic  diathesis. 

In  all  cases,  and  especially  in  these  last,  acetanilide  will  relieve 
the  pain  of  menstruation.  It  is  as  valuable  as  any  of  the  high-priced, 
licensed  and  patented  "  coal-tar  derivatives."  There  is  no  good  reason 
for  combining  it  with  alkalies  or  with  caffeine,  as  in  the  popular  secret 
mixtures.  Like  its  chemical  cousins,  it  is  directly  depressant  and  ulti- 
mately destructive  to  the  most  important  elements  of  the  blood  or 
probably  to  the  tissues,  and  its  anodyne  effect  is  produced  by  paralysis  of 
nerve-endings.  That  it  is  a  poison  in  all  doses  should  be  remembered, 
and  it  should  only  be  used  as  a  makeshift,  or  as  antagonizing  the  rheu- 
matic poisons.  It  is  distinctly  contraindicated  in  anemic  or  debilitated 
patients.     Cyanosis,  sweating,  and  dark  urine,  show  overdosing. 

As  an  anodyne,  an  antispasmodic,  and  remotely  as  a  hypnotic, 
morphine  is  an  ideal  drug  in  the  treatment  of  dysmenorrhoea.  Its 
deleterious  effects  upon  the  digestive  tube  are  such  that  it  should  be 
reserved  for  emergencies.     Xine  out  of  ten  female  morphine  habitues 


i6 


?,9 


A  TEXT-BOOK  OF   GYNECOLOGY 


have  learned  to  use  this  seductive  poison  from  its  emplojanent  originally 
in  the  treatment  of  dysmenorrhoea.  The  physician  who  uses  it  should 
never  name  the  drug  in  the  presence  of  the  patient,  and  the  possibility 
of  having  a  prescription  refilled  should  be  wholly  forestalled.  The 
active  treatment  of  anemia  and  chlorosis  in  the  intermenstrual  period 
■will  be  the  best  treatment  for  dysmenorrhcea  in  many  cases  which 
have  no  pelvic  disease  or  defect. 

Fermentative  dyspepsia  is  relatively  common  among  dysmenor- 
rhoeics.  It  is  sometimes  necessary  to  treat  this  complication  most 
actively.  Active  purgation  just  before  menstruation  has  more  than  a 
palliative  effect  on  dysmenorrhoea  in  some  cases:  it  reduces  pelvic  con- 
gestion, and  possibly  assists  in  ridding  the  system  of  poisons  which  tend 
to  neuralgia.  Heat  is  an  admirable  palliative.  Patients  will  usually 
suffer  less  when  rolled  up  in  a  superfluity  of  blankets.  Hot  footbaths 
and  sitz  baths  give  an  amount  of  relief  which  freshly  shows  the  patient 
that  congestion  and  pelvic  pain  are  linked  together.  Great  comfort 
is  oftentimes  obtained  by  chasing  the  sharpest  pain  from  the  sacrum  to 
the  abdomen,  and  back  again,  by  the  application  of  a  bag  of  hot  water. 
Membranous  Dysmenorrhoea. — In  some  cases  of  dysmenorrhcea  the 
pain  seems  to  be  intimately  associated  with  the  appearance  of  a  mem- 
brane in  the  form  of  a  three-cornered  pocket  (Fig.  298),  or  of  shreds 

and  patches.  In  a  very  few 
cases  the  membrane  gives  a 
copy  of  the  cervical  canal. 
Some  authors  have  held 
the  membrane  to  be  the  re- 
sult of  a  slight  exaggeration 
of  the  normal  process  of 
shedding  of  epithelium ; 
others  hold  it  to  be  an  ex- 
foliation of  the  entire  mu- 
cous membrane  instead  of 
its  superficial  layer;  others 
see  in  it  the  ^^lastic  lymph 
of  metritis  organized; 
others,  with  less  charity  for 
unmarried  patients,  hold  it 
to  be  the  decidua  vera  of  a 
pregnancy  which  has  come 
to  an  early  termination. 

And  there  is  a  similar 
disagreement  as  to  the  im- 
mediate cause  of  the  pro- 
duction of  this  membrane. 
Literature  shows  that  it  may  be  due  respectively  to  flexions,  versions, 
an  OS  too  small  or  too  large,  a  constricted  cervical  canal,  a  constricted 
internal  os,  congestion  of  the  mucous  membrane,  hypertrophy  of  the 


Fig.  298. — "  A  membrane  in  the  form  of  a  three- 
cornered  pocket." — MiLLiKix. 


THE   DISORDERS   OF   MENSTRUATION  733 

mucous  membrane,  hypertrophy  of  the  uterus,  metrorrhagia,  disease 
of  the  ovary,  anaemia,  chlorosis,  syphilis,  and  hysteria.  Nevertheless 
many  of  the  subjects  of  the  affection  are  exceedingly  healthy  women 
and  some  of  them  menstruate  with  so  little  pain  as  to  make  the  term 
dysmenorrhoea  inapplicable. 

In  the  present  state  of  our  knowledge,  it  is  safe  to  say  that  the 
characteristic  exuviae  are  the  product  of  an  endometritis  of  low  grade. 
The  membrane  does  not  differ  in  any  appreciable  degree  from  that 
which  is  sometimes  thrown  oft'  in  cases  of  acute  phosphorus  poisoning, 
in  typhus  fever,  and  in  cholera.  It  has  been  precisely  imitated  by 
severely  cauterizing  the  interior  of  the  uterus,  for,  following  that  pro- 
cedure, there  has  sometimes  appeared  a  three-cornered  sac  consisting 
of  fibrous  tissue  "  faced  with  a  mosaic  of  cylinder  epithelium." 
Schonheimer  has  had  the  opportunity  of  studying  the  membranes 
cast  oft'  by  a  woman  who  was  sterile  and  had  one  thick  tube,  and  he 
found  nothing  notable  except  fibrinous  deposit  full  of  leucocytes  and 
uterine  epithelium.  In  this  case  dilatation  and  curettage  brought  away 
normal  endometrium. 

Membranous  dysmenorrhoea  usually  appears  in  early  menstrual  life. 
It  may,  however,  appear  later,  to  the  dismay  of  the  patient.  Cook 
{Chicago  Medical  Observer,  February,  1898)  reports  the  case  of  a  single 
woman,  thirty-five  years  of  age,  who  had  often  passed  shreds  of  mem- 
brane, but  who  came  under  suspicion  of  pregnancy  by  passing  a  com- 
plete cast  of  the  interior  of  the  uterus  while  visiting.  Under  his  ob- 
servation she  passed  similar  casts  for  two  successive  months.  In 
Schonheimer's  second  case,  the  woman  had  borne  six  children  without 
anything  anomalous  in  her  menstruation.  After  bearing  these  children 
she  began  to  pass  a  uterine  cast  without  pain  at  every  third  period. 

The  affection  sometimes  disappears  as  abruptly.  Coughlin  {New 
Yorlc  Medical  Journal,  December  9,  1899)  records  the  case  of  a  virgin, 
thirty-one  years  of  age,  who  passed  the  characteristic  membrane  with 
great  suffering.  She  was  under  observation  afterward  for  some  time 
and  had  no  recurrence. 

The  affection  is  exceedingly  rare.  Kleinwaechter  made  a  collection 
of  all  accessible  reports  of  cases  and  could  only  find  80  cases  recorded 
{Wiener  Klinilc,  February,  1885). 

The  membrane  is  seldom  passed  at  a  first  menstruation.  It  is  most 
common  between  twenty  and  thirty  years  of  age.  Nearly  80  per  cent 
of  cases  recorded  occur  in  married  women.  Relative  sterility  belongs 
to  the  disease;  only  9.5  per  cent  of  the  cases  in  married  women  become 
pregnant.    Pregnancy  does  not  appear  to  be  curative  in  any  degree. 

The  symptomatology  of  membranous  dysmenorrhoea  is  simply  pain 
and  the  appearance  of  the  membrane.  The  pain  is  not  always  severe, 
nor  is  it  always  promptly  relieved  by  the  appearance  of  the  membrane. 
The  flow  is  preternatural ly  great,  though  there  are  exceptions  to  this 
rule.  The  increased  flow  is  explained  by  the  facts,  that  there  is  a 
large  surface  suddenly  denuded,  and  that  the  membrane,  as  soon  as  it 


734  A  TEXT-BOOK  OF   GYNECOLOGY 

becomes  a  foreign  body,  acts  as  a  stimulant  and  irritant  to  the 
uterus. 

Wlien  membranous  dysmenorrhcea  lias  no  history  it  will  require  a 
microscopic  investigation  to  exclude  abortion  from  the  possibilities. 
After  the  affection  has  continued  for  some  months,  abortion  is  certainly 
excluded.  IvTevertheless  there  are  some  sterile  Avomen  who,  between 
shame  and  hope,  will  tell  of  12  and  13  abortions  in  a  year. 

The  treatment  of  membranous  dysmenorrhcea  by  divulsion  has  not 
been  satisfactory.  Here  and  there,  a  nulliparous  patient  who  passes 
large  membranes,  has  received  benefit.  The  curette  usually  brings 
away  normal  endometrium,  and  makes  no  impression  on  the  next  men- 
struation. Strong  applications  of  phenol,  iodine,  nitrate  of  silver,  caustic 
potash  and  nitric  acid  have  been  used  with  a  vague  hope  of  reconstitut- 
ing the  endometrium  for  the  better;  but  it  has  been  altered  not  a  whit. 
Cauterant  applications  of  electricity  have  not  succeeded  better.  Gun- 
ning {American  Journal  of  Obstetrics,  April,  1891)  reports  a  softening 
and  disintegration  of  the  membrane  after  a  series  of  treatments  by 
mild  currents  of  galvanic  electricity.  He  places  the  negative  pole  at 
the  fundus  and  the  positive  pole  Just  within  the  external  os.  His  first 
current  is  as  light  as  5  milliamperes.  After  a  few  seances  the  current 
is  raised  to  10  milliamperes  continued  for  five  minutes  and  repeated 
every  three  days. 

Intermenstrual  Pain. — Intermenstrual  pain  is  here  considered  be- 
cause it  has  its  relations  to  the  menstrual  period.  Coming  between 
the  periods  it  certainly  can  not,  in  strictness,  be  allied  to  dysmenor- 
rhcea. 

Intermenstrual  pain  is  referred  almost  invariably  to  one  ovarian 
region  or  the  other.  In  some  patients,  the  pain  changes  from  one  side 
to  the  other  from  month  to  month.  If  there  is  an  overfloAV  of  pain 
from  the  ovarian  region,  the  iliac  fossa,  groin,  and  thigh,  are  affected. 
Sacral  pain  is  not  characteristic  of  this  affection.  No  change  of  pos- 
ture will  alter  the  character  or  amount  of  the  pain.  The  pain  is  dis- 
tinctly paroxysmal  and  intermittent  in  character.  The  attacks  are 
brief,  lasting  two,  three,  or  four  days,  in  most  cases.  Fever  is  not 
observed. 

As  to  the  time  of  attack,  each  case  is  a  law  unto  itself.  Palmer 
(American  Journal  of  Obstetrics,  1892)  reports  a  case  in  which  the  pain 
came  on  four  days  and  a  half  after  the  cessation  of  menstruation,  but 
this  is  unusual.  In  his  second  case,  the  pain  appeared  about  eight  days 
after  the  cessation,  and  in  his  third  case,  about  eleven  days  after.  Wil- 
liam 0.  Priestley  gives  two  cases  in  which  the  pain  came  on  fourteen 
days  before  menstruation.  Thomas  and  Munde  give  cases  in  which  the 
pain  appeared  at  nine,  ten,  and  seven,  days  after  menstruation  ceased. 
Some  reporters  vaguely  speak  of  attacks  covering  four  or  five  days  in 
the  middle  of  the  intermenstrual  period.  One  of  Palmer's  patients 
began  to  have  the  intermenstrual  pain  after  confinement.  She  suffered 
ten  years,  then  had  an  abortion  followed  by  severe  pelvic  inflammation. 


THE   DISORDERS  OP  MENSTRUATION  735 

then,  after  a  slow  recovery,  experienced  some  relief,  the  attacks  becom- 
ing milder,  shorter,  and  less  frequent. 

No  pathology  has  been  suggested  for  this  curious  affection  other 
than  that  which  attributes  the  pain  to  an  ovary  which,  by  the  slow 
changes  of  inflammation,  has  become  so  dense  as  to  make  the  passage 
of  the  ovule  from  the  deeper  layers  a  very  difficult  one.  By  hypothesis, 
there  is  some  definite  date  for  each  woman,  at  which,  measured  from 
the  close  of  menstruation,  active  preparation  for  the  ripening  and  ex- 
trusion of  an  egg  begins.  This  hypothesis  involves  the  doctrine  that 
pain  is  produced  by  tension  about  the  growing  follicle,  and  that  the 
pain  ceases  abruptly  when  the  follicle  finally  fights  its  way  to  the 
surface  of  the  ovary  and  is  free  to  ripen  and  rupture.  The  doctrine 
harmonizes  the  facts,  that  the  cases  do  not  present  much  uterine  dis- 
ease, that  several  of  them  at  autopsy  have  shown  dense  ovaries,  and 
that  the  patients  are  relatively,  though  not  absolutely,  sterile.  An- 
other and  more  tenable  theory  is  that  the  pain  is  caused  by  ovarian 
adhesions  which  are  placed  upon  tension  by  the  periodical  recession 
of  the  menstrual  blood  pressure,  a  recession  which  reaches  its  climax 
about  the  middle  of  the  intermenstrual  period. 

Treatment  is  as  inefficient  as  this  pathology  would  indicate.  Some 
have  held  that  benefit  was  given  by  tampons  of  ichthyol  and  boro- 
glyceride,  and  the  great  "  alteratives,"  iodine,  arsenic,  and  mercury, 
given  for  a  long  time.    During  the  paroxysms,  anodynes  must  be  used. 

Vicarious  Menstruation. — If  menstruation  implies  the  casting  ofl! 
of  endometrial  elements,  then  the  term  vicarious  menstruation  can 
only  be  justified  on  the  plea  that  it  is  convenient,  for  it  certainly  is 
inaccurate.  The  term  vicarious  hemorrhage  has  been  proposed,  but 
this  is  equally  inexact  in  that  it  carries  the  implication  that  hemor- 
rhage is  an  essential  part  of  menstruation  instead  of  a  mere  incident. 
We  therefore  use  the  older  term,  vicarious  menstruation,  arbitrarily,  as 
indicating  no  more  than  hemorrhage  which  appears  from  some  part  of 
the  body  other  than  the  uterus  and  in  response  to  the  menstrual 
molimen. 

Though  the  cervix  uteri  has  no  part  in  ordinary  menstruation,  it 
is  such  a  near  neighbour  to  the  uterus  that  we  might  expect  it  to 
be  the  source  of  vicarious  discharges.  Few  cases  are  recorded.  Ash- 
ton  (PhiladelpJiia  Medical  Bulletin,  November,  1898)  gives  an  account 
of  a  woman  from  whom  he  removed  cancerous  ovaries,  whereupon  she 
began  to  menstruate  at  the  rate  of  four  or  five  days  every  two  weeks. 
He  soon  had  occasion  to  remove  the  uterus  close  to  the  vaginal  junction 
and  closed  the  wound  with  peritoneum,  whereupon  she  began  to  men- 
struate scantily  from  the  cervix,  every  four  or  five  weeks. 

The  tubes  have  occasionally  presented  at  fistulse  in  the  abdominal 
wall,  and  in  a  large  proportion  of  cases  yield  a  red  discharge  at  the 
time  of  menstrual  molimen. 

In  ventro-fixation  of  any  part  of  the  pelvic  organs  after  operation, 
vicarious  h(;morr]iage  has  occurred.     Thus,  in  1884,  Rein  showed  a 


736  A  TEXT-BOOK  OF   GYNECOLOGY 

woman  from  whom  he  had  removed  an  ovarian  cyst  and  had  fixed 
the  pedicle  in  the  abdominal  wound.  Healing  had  taken  place 
promptly,  but  at  one  point  there  occurred  a  small  slough  just  before 
menstruation,  and  from  that  sloughing  point  came  blood  during  the 
whole  catamenial  period.     This  had  occurred  for  three  years. 

The  flow  does  not  necessarily  come  from  mutilated  genitalia,  but 
may  come  from  other  parts  of  the  body,  particularly  from  the  mucous 
membranes.  The  nose  is  the  most  prone  to  vicarious  menstruation. 
Macnaughton  Jones  reported  {Edinburgh  Medical  Times,  October,  1897) 
a  case  in  which  there  was  no  epistaxis  but  in  which  a  baffling  nasal 
ulcer  was  conquered  only  after  eleven  months'  treatment,  and  during 
the  greater  part  of  this  time  it  was  much  worse  at  the  menstrual  periods. 
Withrow  has  reported  2  cases,  already  cited  in  these  pages  under 
Amenorrhoea,  in  which  there  was  lifelong  amenorrhoea  and  periodical 
ej)istaxis. 

Periodical  hemorrhage  from  the  stomach  has  been  diagnosticated  as 
symptomatic  of  an  ulcer  at  its  onset.  Charles  T.  Parks,  of  Chicago, 
reports  a  curious  case  of  a  woman  who  was  sick  for  eighteen  months, 
and  for  four  months  had  defecated  at  intervals  of  from  one  to  four 
weeks.  For  two  months  after  coming  under  observation  she  failed  to 
menstruate,  and  at  the  proper  menstrual  times  she  vomited  torrents  of 
blood.  Her  mental  and  physical  condition  became  so  bad  that  when 
faecal  vomiting  came  on,  an  exploratory  incision  was  made.  Enlarged 
ovaries  were  removed.  Scybala  in  enormous  quantity  were  expelled. 
The  urine,  which  for  four  months  had  been  reduced  to  one  ounce  per 
diem,  rose  to  normal  amount  and  recovery  ensued. 

Hemoptysis  is  sometimes  due  to  the  menstrual  excitement.  Nor- 
ton {American  Journal  of  Ohsletrics,  February,  1892)  tells  of  a  woman 
who  menstruated  from  the  age  of  fourteen,  with  much  pain  and  cramps. 
At  the  very  first  menstruation  she  had  a  smothered  or  choking  sensa- 
tion followed  by  a  coughing  paroxysm  during  which  she  spat  blood 
freely.  This  was  repeated  after  a  few  hours  and  so  continued  until  the 
fourth  day,  when  the  vaginal  discharge  was  growing  pink.  From  this 
time  the  bloody  expectoration  diminished  to  the  vanishing  point  on 
the  fifth  or  sixth  day.  She  had  a  small  uterus,  high  in  the  pelvis,  with 
a  minute  os.  Nevertheless,  she  became  pregnant  after  five  years  of 
married  life  and,  during  her  pregnancy,  she  continued  to  menstruate 
after  her  fashion,  with  vaginal  discharge  and  bloody  expectoration. 
The  last  menstruation  was  about  ten  days  before  delivery.  During  all 
the  years  that  she  was  under  observation  she  was  a  hysteric.  Chad- 
bourne  {Journal  of  the  American  Medical  Association,  January  22,  1898) 
has  made  the  important  observation  that  many  girls  who  have  periodic 
hemoptysis,  either  synchronous  with  menstruation  or  replacing  it,  have 
incipient  phthisis. 

Sometimes  the  hemorrhage  is  from  the  ear.  Lermoyez  {Societe 
medicale  des  hopitaux)  reported  the  case  of  a  girl  who  had  a  periodic 
discharge  of  noncoagulable  blood  from  the  right  ear.    After  three  years 


THE   DISORDERS   OP   MENSTRUATION  73^ 

of  this  vicarious  discharge,  normal  menstruation  was  established, 
whereupon  the  aural  discliarge  appeared  only  once  in  two  or  three 
months. 

Sometimes  the  weak  point  is  found  at  a  njevus.  Bloom  {Archives 
of  Pediatrics,  September,  1897)  records  the  case  of  a  girl,  sixteen  years 
of  age,  who  bled  from  a  nasvus  of  the  face.  The  hemorrhage  came 
always  two  days  before  menstruation  and  lasted  until  the  end.  After 
two  weeks  there  was  another  slight  bleeding.  Two  teatlike  projections 
furnished  the  blood.  One  of  these  being  ligated,  another  appeared  at 
the  same  site. 

Many  cases  of  bleeding  cicatrices  have  been  reported.  Ker- 
ley  presented  to  the  New  York  Academy  of  Medicine,  November 
18,  1891,  an  Irish  girl  twenty-five  years  of  age.  At  the  beginning  of 
her  menstrual  career  at  the  age  of  fifteen,  she  developed  an  abscess 
at  the  level  of  the  cricoid  on  the  left  side.  From  this  point  there  had 
been  a  discharge  of  bloody  pus  four  days  out  of  every  twenty-eight 
through  the  whole  ten  years.  In  each  intermenstrual  period  the  cicatrix 
healed. 

Vicarious  hemorrhage  is  most  common  from  the  nose.  Next  in 
order  of  susceptibility  come  the  stomach  and  intestines.  The  hemor- 
rhage has  been  observed  to  appear  in  the  retina  and  under  the  con- 
junctiva. The  vocal  cords,  the  nipples,  and  the  bladder,  have  also 
been  the  seat  of  vicarious  bleeding.  We  have  no  philosophy  for  this 
remarkable  phenomenon,  save  the  doctrine  repeatedly  expressed  in  this 
chapter  that  the  human  organism  has  inherited,  and  has  intensified, 
a  strong  tendency  to  hemorrhage  at  the  menstrual  time.  So  strong  is 
the  impulse  that  it  is  felt  at  remote  points  in  rare  cases.  We  can  not 
rest  upon  mere  increase  of  arterial  tension,  for  though  there  is  a  slight 
increase  of  tension  at  the  menstrual  period,  it  is  so  slight  that  it  be- 
comes as  naught  when  compared  with  other  variations  of  blood  pres- 
sure. A  case  reported  to  the  Indian  Medical  Record  by  J.  E.  Wallace 
is  instructive  in  this  connection,  for  it  indicates  that  Nature  sometimes 
blindly  confuses  two  discharges  under  the  stimulation  of  the  menstrual 
molimen.  The  subject  was  an  Anglo-Indian  lady  who  menstruated  at 
twelve  years  and  was  married  at  twenty-three.  She  proved  to  be  sexu- 
ally impotent,  incapable  of  orgasm,  and,  after  enduring  eight  months 
of  frigidity,  her  husband  parted  from  her  in  disgust.  Upon  this  ensued 
six  years  of  amenorrhea,  but  during  these  years,  at  regular  menstrual 
intervals,  her  breasts  would  become  hard  and  painful,  and  milk  would 
pour  from  them  freely.  She  had  good  general  health  and  no  pelvic 
pain.  She  laid  on  an  immense  amount  of  fat,  increasing  her  weight 
from  98  to  245  pounds.  At  the  end  of  this  period  of  six  years,  Wal- 
lace adjusted  an  intrauterine  stem  and  a  slight  discharge  of  blood  was 
noted  for  three  days.  Four  weeks  later  she  had  high  fever,  turgid 
breasts  and  resumed  normal  menstruation,  and,  at  the  time  of  the  re- 
port, she  had  so  continued  to  menstruate  for  six  months.  During  this 
last  period  the  mammary  engorgement  had  diminished,  and  she  had  lost 
48 


738  A   TEXT-BOOK   OF  GYNECOLOGY 

28  pounds.  It  would  appear  that  the  brief  irritation  of  the  uterine 
stem  had  determined  the  direction  of  overflow  for  this  singular 
case. 

The  Menopause. — The  menopause,  or  the  cessation  of  the  menses, 
is  an  incident  in  the  grand  climacteric  which  comes  to  men  and  women 
alike,  but  comes  to  women  earlier  as  a  penalty  for  their  earlier  ma- 
turity. There  need  be  no  mystery  as  to  its  causes;  when  the  geni- 
talia have  reached  an  age  approximating  half  a  century,  it  is  proper 
that  they  should  be  subject  to  senile  changes.  When  we  consider  the 
profound  changes  in  skin,  hair,  arteries,  Peyer  s  patches,  the  intes- 
tinal villi,  and  crystalline  lens,  at  this  time  of  life  we  are  prepared  to 
admit  that  the  ovaries  may  be  developing  fibrous  tissue  and  may  be 
losing  the  power  of  producing  ovules,  and  that  the  uterus,  with  its 
diminishing  possibilities  of  gravidity,  is  also  undergoing  atrophic 
changes  which  are  truly  senile. 

Making  a  mystery  where  there  is  none,  some  have  assumed  that 
during  the  menstrual  years  the  ovaries  secrete  a  certain  substance 
which  determines  the  menstrual  flux  and  ministers  to  female  health. 
Napier  and  Christopher  Martin  have  held  that  this  hypothetical  sub- 
stance being  lacking  at  the  menopause,  gives  rise  to  some  of  the 
symptoms  of  the  climacteric.  But  it  should  be  remembered  that 
shoals  of  men,  women,  and  children,  live  in  health  without  active 
ovaries,  or  with  none  at  all,  yet  have  good  health,  and  that  the  cli- 
macteric is  not  a  pathologic  process  or  the  menopause  a  symptom. 

The  vulgar  rule  which  gives  to  each  woman  thirty  years  of  men- 
strual life  allows  her  too  little.  The  menstrual  career  is  more  than 
thirty-one  years.  Raciborski  found  that  Parisian  girls  menstruated 
first  at  about  the  age  of  fourteen  years  and  seven  months,  and  that 
the  women  ceased  menstruating  at  forty-six  years  and  six  months. 
Tilt,  upon  knowledge  of  more  than  a  thousand  cases,  comes  to  almost 
identical  figures.  There  is  no  doubt  that,  within  the  past  two  genera- 
tions, civilization  has  increased  the  menstrual  period  as  it  has  length- 
ened life. 

When  the  menopause  is  accomplished  early  in  life,  it  has  some- 
times been  foimd  at  necropsy  that  atrophy  of  ovaries  had  advanced, 
and  in  some  cases  hard,  subperitoneal  fibroids  have  been  found. 
Tumours  which  have  a  mural  or  submucous  situation  tend,  in  gen- 
eral, to  maintain  the  menstruation  to  the  age  of  fifty,  or  beyond  that. 

The  uterus  is  said  to  become  a  trifle  larger  and  heavier  at  the 
beginning  of  the  menopause.  Whether  this  is  true  or  not,  it  is  cer- 
tain that  the  tendency  is  presently  toward  atrophy.  The  walls  be- 
come demonstrably  thinner ;  the  cervix  becomes  shorter  and  thinner ;. 
the  OS  internum  is  sometimes  obliterated ;  the  uterus  is  smaller  in  all 
dimensions;  the  endometrial  glands  become  smaller,  and  their  num- 
bers diminish. 

The  rule  is  that  the  uterus  atrophies  later  than  the  tubes  and 
ovaries.     A  competent  observer  has  found  the  ovaries  of  normal  size 


THE  DISORDERS   OF.  MENSTRUATION  739 

three  years  after  the  menopause^,  and  it  is  known  that  ovulation  is 
often  prolonged  for  years  after  the  uterus  has  ceased  its  functions. 

Changes  in  the  ovaries  at  the  time  of  the  menopause  have  been 
studied  by  Otroschkevitch  {Vratch),  who  has  come  to  the  following 
conclusion : 

"  The  lessening  of  both  ovaries  in  old  age  arises  in  connection  with 
increased  growth  of  fibrous  connective  tissue  and  the  predominance 
of  this  over  the  degenerating  follicles.  The  disappearance  of  the 
epithelium  covering  the  surface  of  the  ovaries  which  occurs  in  old 
age  can  not  always  be  put  down  to  separation  during  preparation  of 
microscopical  specimens,  but  must  rather  be  taken  as  one  of  the  true 
changes  in  the  senile  ovaries.  Desiccation  of  mature  and  wholesale 
degeneration  of  the  primordial  follicles  forms  one  of  the  chief  and 
most  important  changes  in  senile  ovaries.  Hyaline  degeneration  of 
the  arteries  and  fibrous  tissue  progresses  with  age,  and  in  very  ad- 
vanced age  striking  examples  of  this  degeneration  are  found.  Fatty 
degeneration  of  the  cellular  skeleton  occurs  fairly  often,  and  is  evi- 
dently dependent  upon  the  deficient  nutrition  of  the  ovary.  A  direct 
connection  between  degeneration  of  the  vessels  and  diminution  in 
function  of  the  ovaries  is  not  substantiated,  for  the  ovary  becomes 
limited  in  function  when  there  are  still  but  few  vessels  affected  by 
degeneration  and  therefore  at  a  time  when  its  nutrition  is  but  little 
altered.  The  nervous  system  plays  the  chief  part  in  the  complex 
process. ^^ 

At  the  menopause,  women,  like  men  at  a  corresponding  age,  suffer 
from  a  deposit  of  fat  which  is  oftentimes  a  serious  burden.  The 
masses  deposited  in  the  abdominal  wall  and  in  the  omentum  are 
absorbed  in  great  degree  in  later  life,  or,  as  some  think,  are  simply 
redistributed.  The  mesentery,  also,  takes  on  a  large  amount  of  fat. 
About  the  heart,  in  the  pericardium,  and  in  the  subpericardial  con- 
nective tissue,  the  accumulation  of  fat  becomes  very  embarrassing, 
leading  to  such  serious  symptoms  as  hurried  respiration,  cardiac 
asthma,  cardiac  palpitation,  venous  stasis,  and,  in  the  worst  cases,  to 
albuminuria  and  oedematous  feet  and  legs.  1 

About  one  woman  in  ten  will  be  annoyed  while  at  the  menopause, 
by  flashes  of  heat  running  over  the  face  and  neck,  and  sometimes 
sweeping  over  the  whole  body.  The  heat  is  a  subjective  sensation  and 
is  not  real.  The  sensation  is  caused  by  a  temporary  vasomotor  paral- 
ysis which  permits  the  extreme  dilatation  of  the  small  vessels.  Some- 
times profuse  sweating  follows  these  waves. 

Metrorrhagia  has  no  place  among  the  normal  phenomena  of  the 
menopause.  It  occurs  rarely,  though  the  folklore  of  the  women  keeps 
them  dreaming  of  torrents  of  blood  at  the  change  of  life.  Scanzoni 
himself  endeavoured  to  explain  the  profuse  hemorrhages  of  the  meno- 
pause by  assuming  a  great  friability  of  the  blood  vessels,  and  Kisch 
has  taught  that  the  softening  and  relaxation  of  the  uterine  substance 
is  the  cause.    But,  as  a  matter  of  fact,  their  theories  are  superfluous, 


740  A  TEXT-BOOK  OF   GYNECOLOGY 

for  hemorrhage  is  not  an  incident  pertaining  to  the  menopause. 
Metrorrhagia^  when  it  does  occur  at  that  time  of  hfe,  is  usually  in- 
duced by  some  one  of  the  ordinary  causes  which  we  have  enumerated 
elsewhere.  Baer  (American  Journal  of  Obstetrics,  May,  1884)  has 
analyzed  2,200  cases  of  metrorrhagia,  and  shows  that  the  profuse 
hemorrhage  belongs  to  the  early  years  of  greatest  fecundity  and  to 
any  period  of  menstrual  life  rather  than  to  the  menopause.  In  five 
years  following  the  age  of  twenty-nine  there  were  364  cases;  in  five 
years  following  the  age  of  thirty-four,  333  cases;  in  five  years  fol- 
lowing the  age  of  thirty-nine,  223  eases;  in  five  years  following 
forty-four  years,  131  cases.  In  the  years  between  twenty  and 
forty  there  were  1,533  cases,  and  there  were  only  667  cases  for  all 
other  ages. 

It  is  at  the  menopause  that  inhibition  fails  and  lurking  cancer 
advances  by  leaps.  Any  metrorrhagia  at  this  time  of  life  should 
excite  suspicion  of  cancer.  A  serous  discharge  is  sometimes  the 
warning  of  cancer,  and  sometimes  of  senile  endometritis. 

With  the  atrophy  of  the  hypogastric  plexus  come  some  disturb- 
ances of  the  sympathetic  nervous  system,  though  the  reflex  disturb- 
ances of  the  stomach  and  intestines  at  the  menopause  have  certainly 
been  exaggerated  in  medical  literature.  The  dyspepsia  of  this  time 
of  life  is  not  iDeculiar  to  females.  Many  alert  practitioners  have 
worked  through  a  lifetime  without  seeing  the  alleged  diarrhoea  of  the 
change  of  life. 

The  heart  is  more  disturbed  at  this  time  than,  perhaps,  any  other  or- 
gan. By  far  the  larger  number  of  cases  of  tachycardia  in  women  appear 
at  the  very  first  announcement  of  the  menopause.  It  is  a  noticeable 
fact  that  tachycardia  is  most  likely  to  afflict  those  who  experience  the 
menopause  early  in  life.  Few  cases  have  come  to  autopsy,  but  those 
few  have  almost  invariably  confirmed  the  theory  that  the  tachycardia 
belongs  to  the  exceptional  cases  in  which  there  is  early  shrivelling 
of  the  ovaries  with  hyperplasia  of  connective  tissue,  and  it  is  a  part 
of  the  theory  that  the  nervous  reflex,  doubtless  a  stimulation  of  the 
accelerators,  proceeds  from  the  cirrhotic  ovaries.  Tachycardia  is  also 
common  in  eases  in  which  the  operations  on  pelvic  organs  have  caused 
adhesions.  Tachycardia  should  be  carefully  distinguished  by  the 
strong,  full,  regular  pulse,  the  irritable  disposition,  the  throbbing 
aorta,  the  constriction  of  the  chest,  and  the  high  percentage  of  hemo- 
globin, from  the  weak  heart,  announced  by  a  weak  and  fluttering, 
easily  compressible  pulse,  and  the  low  ratio  of  hemoglobin  which 
accompanies  this  sort  of  debility. 

Glycosuria  is  sometimes  present  in  the  years  about  the  menopause. 
The  prognosis  is  not  so  grave  in  these  cases  as  in  glycosuria  in  gen- 
eral, for  the  theory  of  causation  permits  us  to  believe  that  the  disease 
is  produced  by  irritation  of  the  sympathetic  supply  of  the  liver,  and 
permits  us  to  hope  that  when  the  immediate  nervous  irritation  from 
ovaries  and  uterus  shall  have  ceased  by  atrophy,  there  Mdll  be  a  tend- 


THE   DISORDERS   OP   MENSTRUATION  741 

ency  toward  recovery.  In  many  of  these  cases  of  glycosuria,  vulvar 
pruritus  is  the  danger  signal. 

Early  in  the  menopause  there  is  sometimes  noticed  a  curious  men- 
tal exaltation.  While  it  lasts  the  woman  becomes  inclined,  perhaps, 
to  meddle  with  business  affairs  which  concerned  her  not  in  earlier 
life;  she  has  large  plans;  she  essays  large  tasks;  she  proposes  for 
herself  all  that  is  difficult  or  impossible.  It  is  a  state  of  mind  which 
does  not  last  long. 

Far  more  frequently,  the  mental  condition  of  the  menopause  is 
one  marked  by  depression.  The  sane  woman  at  the  change  of  life 
is  one  who,  as  a  rule,  suffers  depression  rather  than  mental  exalta- 
tion. If  the  perturbation  of  the  time  drifts  into  a  positive  mental 
alienation,  it  is  likely  to  take  the  form  of  melancholia  and  hypochon- 
dria, and  passive  forms  of  hysteria.  JSTot  that  more  active  forms  of 
insanity  are  excluded.  At  this  period  may  appear  strong  irrespon- 
sible impulses,  active  moral  perversions,  delirium  and  acute  mania. 
Of  these,  and  of  all  sorts  of  insanity,  it  may  be  said  that  the  prognosis 
is  good  if  there  are  not  too  many  neurotic  defects  in  the  ancestry. 

At  the  menopause,  that  which  seems  to  be  an  insanity  or  a  radical 
change  of  character,  newly  acquired,  is,  upon  close  study,  seen  to  be 
merely  an  exfoliation  of  mental  habits  formed  in  the  best  years  of 
life.  Thus  stripped,  the  patient  returns  to  her  earlier  mental  condi- 
tion revealing  traits  which  were  suppressed  through  her  young 
womanhood.  In  one  woman  we  may  see  something  of  childlike  trust- 
fulness and  pliability  appear;  in  another,  disagreeable  childish  traits 
appear  when  the  veneer  has  been  peeled  off;  and  she  who  was  tidy  is 
slovenly  in  her  house  or  her  person,  becomes  stubborn  about  small 
matters  and  is  absolutely  frivolous  in  conversation  and  in  behaviour. 
Addiction  to  alcohol  and  other  nerve-tickling  drugs  sometimes  be- 
comes pronounced  at  this  time,  and  the  demand  for  these  drugs  seems 
to  have  no  other  basis  than  childish  ennui  and  a  babyish  lack  of  self- 
control.  The  patient,  no  longer  busy  in  life,  no  longer  self-centred, 
can  not  abide  solitude  and  relies  wholly  on  company.  She  becomes 
exacting  in  small  matters,  and  jealous,  not  of  her  husband  alone,  but 
of  all  upon  whom  she  has  claims.  It  is  a  curious  fact,  and  fortunate, 
that  many  such  cases,  having  fallen  into  this  advanced  senile  state, 
will  work  out  of  it  again  and  go  through  many  years  of  later  life  sane 
and  serene. 

jSTo  doubt  we  pay  too  much  attention  to  the  physical  changes  ac- 
companying the  menopause  and  too  little  to  the  tremendous  mental 
change  which  comes  to  every  woman  at  that  period  of  life.  A  man 
grows  old  by  merciful  and  gentle  gradations,  and  so  he  slides,  half 
willingly,  and  half  unconsciously,  into  the  afternoon  of  life,  with 
regrets  so  soft  that  they  can  scarce  provoke  a  sigh.  But  for  a  woman, 
man's  twenty  years  of  gentle  change  are  compressed  into  two;  she  is 
rudely  compelled  to  make  an  abrupt  change  of  mental  attitude  as 
regards  life  and  love,  and  the  big  world  arid  the  groat  future.     It  is 


Y42  A  TEXT-BOOK  OF  GYNECOLOGY 

evolution  for  him;  it  is  revolution  for  her.  She  is  suddenly  brought 
to  perceive  that  her  charms,  her  youth,  her  sex  itself,  are  passing 
from  her.  She  is  invited,  with  cruel  abruptness,  to  be  to  her  hus- 
band merely  an  intellectual  companion  or  a  sexless  helpmeet,  when 
she  has  been  of  late  the  object  of  his  embraces  and  the  mother  of  his 
babes.  One  third  of  her  adult  life  is  still  before  her,  full  of  promise 
of  placid  enjoyment  and  great  usefulness,  but  to  her,  remembering 
the  glory  of  conquest  and  surrender,  the  future  stretches  a  dreary 
waste  of  empty  years. 

It  appears  small  wonder,  therefore,  that,  with  this  sudden  violence 
done  to  lust  and  love  and  pride  and  hope,  the  woman  at  the  climac- 
teric, finding  a  sharp  boundary  set  to  her  warm  young  life,  beyond 
which  she  must  walk  into  a  gray  and  passionless  old  age,  should  be 
the  victim  of  a  sadness  which  may  drift  into  a  melancholy  and  so  into 
a  madness.  The  explanation  of  the  psychoses  and  the  neuroses  of 
the  menopause  is  not  to  be  sought  in  absolute  senility,  nor  in  the 
accimmlation  of  menstrual  poisons,  nor  in  the  lack  of  ovarian  juices, 
so  much  as  in  the  suddenly  changed  mental  atmosphere  of  her  who 
stands  reluctantly  between  youth  and  age,  bereft  of  all  that  she  most 
valued  in  herself. 

Treatment. — The  menopause,  itself,  needs  no  treatment.  But 
since  it  is  a  season  of  nervous  depression,  and  a  time  when  the  vital 
powers  are  failing,  latent  diseases  and  defects,  hitherto  well  borne  or 
suppressed,  assert  themselves. 

The  gouty  diathesis  or  the  rheumatic  taint  may  demand  treatment 
by  elimination,  regulated  diet,  and  prescribed  muscle  waste.  A  syphi- 
lis may  need  a  course  of  treatment  after  it  has  been  forgotten  for 
years. 

Perineal  and  cervical  lacerations,  hemorrhoids  and  varices,  may 
cry  for  attention,  not  merely  because  the  menopause  is  at  hand,  but 
because  the  woman  is  no  longer  young,  and  repair  is  slow,  resisting 
power  is  lessened,  and  inhibition  by  the  higher  centres  over  the  irri- 
tated lower  centres  is  withdrawn  in  some  degree. 

Climacteric  fat  may  become  a  burden  so  grievous  that  the  inges- 
tion of  hydrocarbons  must  be  restricted,  drink  must  be  limited,  and 
vapour  baths  and  physical  exercise  must  do  the  rest. 

Dyspepsia,  diarrhoea  and  constipation  may  be  so  extreme  as  to  be 
interpreted  as  manifestations  of  profound  disturbance  of  the  sym- 
pathetic supply  of  the  intestines  by  an  irritation  proceeding  from 
the  genitalia.  At  this  time,  errors  of  diet  and  regimen  will  tax  the 
patience  of  the  physician  who  would  detect  and  correct  them. 

The  circulatory  disturbances  of  the  menopause  are  mostly  affec- 
tions showing  stimulation  of  the  accelerators.  Digitalis  is  much 
abused  in  these  cases.  Veratrum  viride  is  more  indicated  when  a 
sound  heart  is  to  be  dealt  with. 

The  heart  is  not  involved  in  the  curious  flushes  and  subjective 
flashes  of  heat.     The  bromides,  used  with  due  regard  to  their  depress- 


THE  DISORDERS  OF   MENSTRUATION  743 

ing  effect,  will  yield  very  good  results  in  these  eases.  Many  women, 
when  they  are  made  to  understand  the  nature  of  these  sensations,  do 
not  care  to  have  treatment  for  them. 

Insomnia  is  a  very  troublesome  symptom  of  this  time  of  life,  and 
will  demand  careful  treatment.  The  patient  may  take  a  certain 
amount  of  hypnotics,  but  always  with  the  knowledge  that  they  are 
great  evils,  introduced  only  for  emergencies,  and  that  the  main  re- 
medial agents  must  be  open-air  life,  moderate  fatigue  at  bedtime,  a 
mind  at  rest  and  plain  food.  The  attendant  who  is  justified  in  the 
occasional  use  of  hypnotic  medicines  will  do  well  to  keep  his  own 
counsel,  and  never  permit  the  name  of  the  drug  to  cross  his  lips, 
attributing  each  sound  sleep  to  anything  other  than  the  drug  he  has 
used.  If  his  wakeful  patient  becomes  his  confidante  he  will  find  him- 
self unable  to  bafSe  her  when  she  sets  herself  to  use  drugs  for  the 
induction  of  sleep  at  her  own  pleasure. 

Tachycardia,  mild  or  severe,  occurring  at  the  menopause,  will  usu- 
ally end  in  recovery  when  the  ovaries  have  had  time  to  lose  their 
nerve  elements  and  have  ceased  to  tease  the  sympathetic  system.  The 
cases  in  which  there  is  a  dilatation  of  the  heart  do  not  tend  to  recov- 
ery, though  they  usually  improve  after  the  patient  has  ceased  to 
menstruate  for  some  years.  Plainly,  the  source  of  irritation  is  not 
always  in  the  contracting  ovaries;  tachycardia  has,  in  rare  cases,  come 
to  an  end  after  the  removal  of  cicatricial  tissue  at  a  laceration  of  the 
cervix. 

In  some  few  cases  with  great  nervous  fretting  and  poor  nutrition, 
a  period  of  rest  and  seclusion  away  from  home  may  avert  absolute 
insanity.  This  treatment,  with  high  feeding,  is  indicated  especially 
for  women  who  have  long  been  overworked.  The  beneficial  effects 
upon  the  thoughtless  or  deliberately  cruel  home  people  is  sometimes 
the  chief  justification  for  sanitarium  treatment.  There  are  many 
patients,  on  the  other  hand,  who  are  in  danger  of  grave  psychoses 
because  they  have  nothing  to  do,  and  it  may  be  possible  for  the  physi- 
cian to  suggest  some  avenue  through  which  the  patient  may  find  her 
way  to  useful  work,  renewed  zest  in  life,  and  some  promise  of  a  mind 
at  peace.  Certain  it  is,  that  mere  drug  therapy  can  avail  little  for 
those  who  are  overworked  or  for  those  who  have  no  occupation. 


CHAPTEE    XLA^I 

THE   FEMALE  URINARY  APPARATUS 

Physical  examination — Catheterization  of  the  ureters :  Pawlik-Kelly  method ;  use 
of  the  ureterocystoscope — Harris  urine  segregator — Anomalies  of  the  kidneys  in 
number,  location,  form — Movable  kidney,  etiology,  patliologic  anatomy,  symp- 
tomatology, treatment — Anomalies  of  the  ureters — Stricture  of  the  ureters — 
Nephrocystosis :  Nephrydrosis ;  nephropyosis ;  pathologic  changes,  symptoma- 
tology and  diagnosis,  treatment. 

Physical  Examination. — In  all  examinations  of  the  kidney,  the 
abdomen  should  be  thoroughl)'  exposed  by  the  removal  of  all  cloth- 
ing. The  examination  may  be  made  with  the  patient  lying  on  the 
back,  on  the  side,  or  standing.  When  on  the  back,  the  shoulders 
should  be  slightly  raised  and  the  limbs  drawn  up  to  relax  as  much  as 
possible  the  abdominal  muscles.  With  the  palmar  surface  of  the 
fingers  of  one  hand,  counter  pressure  is  made  posteriorly  Just  below 
the  twelfth  rib,  while  the  other  hand  presses  upward  and  backward 
beneath  the  costal  arch  external  to  the  rectus  muscle.  The  patient 
should  now  take  a  deep  breath,  and  during  the  expiration,  the  anterior 
hand  should  follow  the  receding  abdominal  wall.  The  kidney,  if  it 
descends  far  enough,  may  be  grasped  between  the  hands  and  its  surface 
easily  palpated. 

In  the  side  position,  the  patient  lies  on  the  side  opposite  the  one 
to  be  examined.  The  body  should  be  curved  slightly  forward  and  the 
limbs  drawn  up.  In  this  position  the  kidney,  if  movable,  drops  to- 
ward the  middle  line  and  may  be  more  easily  felt. 

The  standing  position  is  to  be  preferred  when  examining  for  "  pal- 
pable "  kidneys,  for  "  movable  "  kidneys  of  low  degree,  or  when  the 
superior  pole  tilts  forward.  The  body  should  bend  gently  forward 
with  the  hands  resting  on  a  table  or  chair.  The  kidney  can  often  be 
palpated  in  this  position  when  it  can  not  be  felt  lying  down.  The 
kidney  is  recognised  as  such  by  its  shape,  its  range  of  motion,  its  rela- 
tion to  the  colon,  and  its  return  to  the  normal  location  by  manipula- 
tion or  position  of  the  body.  The  shape  can  not  be  better  expressed 
than  by  the  well-understood  expression  "  kidney-shaped."  The  range 
of  motion  of  the  mass  is  of  considerable  diagnostic  value.  In  movable 
kidney,  the  range  of  motion  is  usually  through  an  arc  of  a  circle,  the 
vessels  forming  the  pedicle  representing  the  radius,  while  the  origin  of 
the  vessels  corresponds  to  the  fixed  point  or  centre.  The  majority  of 
744 


THE   FEMALE   URINARY   APPARATUS  745 

,  movable  kidneys  pass  below  the  transverse  colon  and  behind  and  to 
the  inner  side  of  the  longitudinal  colon.  When  the  superior  pole  tilts 
forward,  the  rounded  end  may  be  felt  just  below  the  edge  of  the  liver 
and  above  the  transverse  colon.  It  may  resemble  very  much  an  en- 
larged, distended  gall  bladder,  and  diagnosis  is  often  difficult.  The 
diagnostic  points,  aside  from  the  history,  are  these :  The  kidney  may 
usually  be  felt  with  the  hand  behind  as  well  as  in  front,  which  is  not 
often  the  case  with  the  gall  bladder.  The  kidney  may  be  returned  to 
its  normal  location  by  manipulation  or  when  the  patient  lies  down, 
the  tumour  disappearing;  while  though  the  gall  bladder,  if  it  has  a 
long  mesocyston,  may  be  crowded  back  under  the  liver  thus  partially 
disappearing,  it  tends  to  return  forward  to  its  normal  position  so  soon 
as  the  pressure  is  removed.  A  so-called  "  Schniirlobe  "  of  the  liver 
may  closely  simulate  a  movable  kidney,  but  its  connection  with  the 
liver  can  usually  be  made  out. 

Very  small  tumours  may  rarely  be  detected  in  palpable  kidneys  by 
the  slight  irregularity  or  protuberance  produced  on  the  surface  of  the 
organ.  Tumours  of  the  kidney  that  are  of  sufficient  size  to  form  dis- 
tinct enlargements,  can  usually  be  outlined  without  much  difficulty. 
One  of  the  most  important  diagnostic  points  in  connection  with  these 
tumours  is  the  relation  that  they  bear  to  the  longitudinal  colons.  As 
the  kidney  lies  in  the  retrocolonic  space,  enlargements  of  it  from 
whatsoever  cause  displace  the  colon  forward,  forward  and  inward,  or 
inward.  Deviations  from  this  rule  are  the  exception,  and  occur  usu- 
ally in  enlargements  of  movable  kidneys.  The  relation  of  the  colon 
to  the  tumour  can  always  be  easily  determined  by  having  the  bowel 
thoroughly  emptied;  then  the  tumour  should  be  mapped  out  on  the  sur- 
face of  the  abdomen  and  the  colon  gently  distended  with  air  by  means  of 
an  ordinary  rubber  hand  bulb.  Having  decided  that  a  tumour  is  con- 
nected with  the  kidney,  it  is  next  desirable  to  know  if  it  is  solid  or  cystic. 
This  can  often  be  determined  by  the  sense  of  touch  and  the  presence 
or  absence  of  fluctuation.  At  times,  however,  fluctuation  is  so  doubt- 
ful that  one  is  unable  to  decide.  In  such  a  case,  the  aspirating  needle 
may  be  used  with  the  usual  aseptic  precautions.  It  should  always 
be  introduced  posteriorly  so  that  the  peritoneal  cavity  may  not  be 
entered.  Should  fluid  be  withdrawn,  its  character  will  determine  the 
nature  of  the  enlargement,  whether  simple  cyst,  nephrydrosis,  nephro- 
pyosis,  echinococcus,  etc. 

The  surface  of  the  tumour  should  be  palpated  to  ascertain  if  it  is 
smooth  and  uniform,  or  irregular  and  nodular.  Of  the  former  class, 
are  the  simple  cystomata  and  usually  the  large  rapidly  growing 
"  mixed  tumours  "  of  childhood.  Of  the  latter,  are  congenital  multi- 
ple cystic  kidney,  infected  kidneys  with  multiple  intranephric  and 
perinephric  abscesses,  and  some  malignant  growths. 

Tumours  of  the  kidney  are  usually  movable,  particularly  during 
their  early  stage.  Later,  they  may  become  fixed  by  adhesions  to  sur- 
rounding parts.     A  careful  examination  of  the  urine  is  of  great  im- 


746 


A  TEXT-BOOK  OF  GYNECOLOGY 


Fig.  299.— Urethral 
dilator. — Harris. 


$ 


portance  in  the  diagnosis  of  renal  diseases.  In  order  to  determine 
accurately  the  point  of  origin  of  pathologic  products  in  the  urine,  it 
may,  at  times,  be  necessary  to  collect  the  urines  directly  from  each 
kidney  separately.  This  may  be  done  by  catheterizing 
the  ureters  or  by  the  use  of  the  Harris  urine  segre- 
gator. 

Catheterization  of  the  Ureters. — There  are  two 
methods  at  present  in  use  of  catheterizing  the  ureters. 
These  are  the  Pawlik-Kelly  method  and  the  use  of 
the  ureterocystoscope. 

In  the  Pawlik-Kelly  method  the  instruments  neces- 
sary, as  given  by  Kelly,  are  the  following:  A  conical 
urethral  dilator  (Fig.  299);  several  specula  with  ob- 
turators (Fig.  300),  Nos.  8,  8^,  9,  9^,  10;  a  light;  a 
head  mirror;  an  evacuator;  long  recurved  mouse- 
toothed  forceps  (Fig.  301);  a 
ureteral  searcher  (Fig.  308);  flex- 
ible ureteral  and  renal  catheters; 
a  metal  ureteral  catheter;  hard- 
rubber  bougies,  and  a  series  of 
dilating  catheters.  The  bladder 
should  be  completely  emptied  of 
its  urine  and  the  patient  placed 
in  the  knee-chest  position  on  a 
table.  The  urethral  orifice  should 
be  cleansed  with  a  boric-acid  solu- 
tion, the  urethra  dilated,  if  necessary,  with  the 
conical  dilator,  and  a  properly  sterilized  speculum, 
No.  8,  9,  or  10,  introduced  into  the  bladder.  Upon 
withdrawing  the  obturator  the  bladder  immedi- 
ately distends  with  air.  The  vagina,  likewise,  usu- 
ally distends  with  air,  but  when  it  fails  in  this,  as 
is  likely  in  the  vir- 
gin, it  may  be  neces- 
sary to  introduce 
into  the  vagina  a 
very  small  cylindri- 
cal speculum  or  one       ,.  ,        t.     „„.    ^       , 

„  J ,  -^  ,11  V    ..^^  ^^°-  300.— Speculum  with 

of  the  urethral  spec-        >0^  obturator.-HARRis. 

ula,    when    the    air 

will  readily  enter  and  the  speculum  may  be  withdrawn. 

The  light  is  now  reflected  from  the  head  mirror  into  the 

bladder,  illuminating  it  so  that  its  interior  m.ay  be  readily 

examined.    The  speculum  is  withdrawn  until  the  internal 

end  of  the  urethra  begins  to  fold  over  it.    Now,  by  pushing  it  straight 

in  for  a  distance  of  about  1  centimetre,  and  then  deflecting  it  laterally 

about  25°  or  30°,  the  ureteral  orifice  usually  comes  into  view.    This  has 


THE   FEMALE   URINARY   APPARATUS 


(47 


the  appearance  of  a  small  narrow  slit,  a  slight  elevation  or  papilla, 
or  sometimes  of  a  small  fold  in  the  mucous  membrane.  If  the  ure- 
teral orifice  does  not  readily  present  itself  after  the  end  of 
the  speculum  has  been  directed  to  the  location  where  it 
presumably  ought  to  be,  it  may  be  sought  for  with 
the  searcher.  When  found,  it  should  be  carefully 
wiped  off  with  a  piece  of  cotton  wet  in  boric-acid 
solution,  and  the  catheter  gently  introduced.  If  de- 
sired, the  speculum  may  be  withdrawn,  the  patient 
turned  on  the  back  and  the  catheter  allowed  to  re- 
main until  sufficient  urine  has  been  collected  for 
analysis. 

The  chief  advantages  of  this  method  are  that  the 
instruments  necessary  are  simple  and  inexpensive,  and 
that  it  permits  cleansing  of  the  ureteral  orifice  by 
direct  application  before  introducing  the  catheter. 
The  method,  however,  is  not  so  simple  as  it  appears. 
Much  practice  and  dexterity  are  necessary,  and  nu- 
merous failures  will  be  recorded  by  the  occasional 
user.  Besides,  an  anesthetic  is  often  necessary  in 
order  to  secure  perfect  ballooning  of  the  bladder, 
when  two  trained  assistants  or  a  special  apparatus 
will  be  required  to  hold  the  patient  in  position. 

Catheterization  by  Means  of  the  Cystoscope. — By 
this  method  the  catheter  is  introduced  into  the  ureter 
under  the  guidance  of  the  eye  by  means  of  one  of  the 
ureterocystoscopes,  such  as  Casper's,  Mtze's,  Albar- 
ran's,  Brenner's,  etc.  (Fig.  303).  The  bladder  is  thor- 
oughly cleansed  by  irrigation,  and  about  100  to  150 
cubic  centimetres  of  clear  boric-acid  solution  allowed 
to  remain  in  the  bladder.  The  cystoscope,  prop- 
erly sterilized,  is  then  introduced,  and  the  interior 
of  the  bladder  illuminated  by  the  electric  light.  The 
ureteral  orifice  is  sought  for  by  inspection,  and, 
when  found,  the  catheter,  passed  along  the  small 
canal  in  the  instrument,  is  directed  toward,  and 
made  to  enter,  the  ureter  by  the  sense  of  sight. 

The  Harris  Urine  Segregator  (Fig.  30^ 
By  this  instrument  the  urines  are  collected 
separately  from  each  kidney  without 
the  ureters  being  entered  (Fig.  305).    The 
patient  is  placed  on  the  back  in  an  easy 
lithotomy  position  with  the  hips  on  the 
same  level  as  the  shoulders.     The  blad- 
der,   after    being    thoroughly    cleansed 
by  irrigation,  is  distended  with  about  150  cubic  centimetres  of  sterile 
water.     The  double  catheter,  sterilized  by  boiling,  is  introduced  mto 


Fig.  301. 

Mouse- 
toothed 
forcepf*. 

— HA1U4IS 

(page  Y46). 


ureteral 


(page  74G). 


748 


A  TEXT-BOOK  OF   GYNECOLOGY 


the  bladder  and  the  lever  into  the  vagina.  After  these  two  pieces  are 
locked  by  means  of  the  small  pin  in  the  forked  piece,  the  catheters  are 
opened  and  fastened  by  means  of  the  small  spiral  spring.  The  rubber 
tube  connecting  the  curved  tips  of  the  catheters  is  now  removed  and 


Fig.  303. — "One  of  the  ureterocystoscopes." — Harris  (page  747). 

the  water  within  the  bladder  allowed  to  escape.  The  vials  are  attached 
and,  by  means  of  the  most  gentle  action  of  the  bulb,  the  urine  will  be 
found  to  collect  in  the  vials,  right  and  left  respectively,  as  fast  as  it 
escapes  from  the  ureters.  Each  of  these  methods  has  its  advantages. 
By  means  of  the  cystoscope,  the  interior  of  the  bladder  may  be  accu- 
rately inspected,  and  local  conditions,  such  as  inflammatory  changes, 
ulcers,  incrustations,  new  gTo\^i:hs,  etc.,  recognised.  By  catheterization 
of  the  ureters  the  urine  may  be  collected  and  the  pelvis  of  the  kidney 
drained  and  then  treated  by  irrigation.  The  use  of  ureteral  bougies 
will  often  enable  one  to  recognise  the  ureter  more  readily  in  certain 

operations  in  the  pel- 
vis, or  to  locate  the 
divided  ends  of  an  in- 
jured ureter.  One 
may  be  able  to  detect 
the  presence  and  loca- 
tion of  a  stricture  or 
obstruction  of  the 
ureter,  possibly  to 
dislodge  a  calculus 
from  the  ureter,  and 
rarely  to  detect  a  cal- 
culus in  the  pelvis  of 
the  kidney.  The  great 
disadvantage  of  the 
ureteral  catheter  is  the  danger  of  infecting  a  healthy  ureter  and  kid- 
ney. This  danger  is  so  real  that,  in  the  presence  of  a  septic  bladder, 
or  in  tuberculosis  of  the  bladder  or  of  one  kidney,  a  healthy  ureter 
should  never  be  catheterized  except  under  the  most  urgent  necessity. 

The  great  advantage  of  the  urine  segregator  is  that  it  may  be 
used  without  danger  of  infecting  a  healthy  kidney,  even  if  the  bladder 
is  septic,  as  the  instrument  does  not  enter  the  ureteral  openings. 


Pig.  304. — The  Harris  urine  segregator. — Harris  (page  747). 


THE  FEMALE  URINARY  APPARATUS 


749 


Anomalies  of  the  kidneys  may  be  considered  under  three  heads: 
(a)  Anomalies  of  number;  (b)  Anomalies  of  location;  (c)  Anomalies 
of  form. 

Anomalies  of  Number. — Absence  of  both  kidneys  has  been  observed, 
but  the  condition  is  incompatible  with  prolonged  post-natal  existence. 


Fig.  305. — "  By  this  instrument  the  urines  are  collected  separately  from  each  kidney  without 
the  ureters  being  entered." — Harris  (page  747). 


Absence  of  one  kidney,  provided  the  other  is  normal,  is  perfectly 
compatible  with  health  and  existence  to  old  age.  This  condition  is 
found  in  one  individual  in  about  3,000,  and  is  thus  of  considerable 
surgical  importance.  The  remaining  kidney  is  called  a  "  single  "  or 
"  solitary  "  kidney. 

Ballowitz  (Archiv  filr  pathologische  Anatomic,  Bd.  cxli)  has  collected 
213  cases  of  "  single  "  kidney.  The  left  kidney  was  absent  70  times, 
and  the  right,  42  times,  in  males;  the  left,  31  times,  and  the  right, 
34  times,  in  females.  Eemainder  unstated.  "Wliile  in  men  the 
absence  of  the  left  kidney  distinctly  predominates,  in  women,  the  two 
sides  are  about  equally  represented. 

With  absence  of  a  kidney  is  frequently  found  some  developmental 
defect  in  the  generative  organs  of  the  same  side,  such  as  absence  of 


750  A  TEXT-BOOK  OP   GYNECOLOGY 

the  ovary  and  tube,  and  uterus  unicornis  in  women,  or  absence  of 
the  seminal  vesicle,  vas  deferens,  or  testicle,  or  unilateral  prostate,  in 
men.  In  71  women,  such  defect  was  found  41  times,  while  in  113 
men,  it  appeared  only  28  times.  A  "  single  "  kidney  is  almost  always 
larger  than  normal.  In  116  cases,  the  kidney  was  distinctly  hyper- 
trophied,  while  in  only  5  cases  was  it  found  smaller  than  normal. 
Nephrydrosis,  chronic  inflammatory,  or  other  pathologic  changes,  were 
found  in  nearly  13  per  cent  of  Ballowitz's  213  cases.  "  Single  "  kid- 
ney has  been  unwittingly  removed  a  number  of  times  for  disease,  with 
the  inevitable  death  of  the  patient  as  a  result.  In  all  cases,  there- 
fore, in  which  nephrectomy  is  contemplated,  the  possibility  of  "  sin- 
gle "  kidney  must  first  be  excluded.  In  "  single "  kidney,  almost 
always  but  one  ureter  is  found  opening  into  the  bladder,  and  this  is  of 
great  diagnostic  importance,  but  in  4  cases,  2  ureters  were  found 
opening  into  the  bladder  at  their  normal  locations,  the  one  leading 
to  the  kidney,  the  other  forming  only  a  shorter  or  longer  blind  tube. 
"  Single "  kidney  usually  occupies  the  normal  location  on  one  or 
the  other  side,  but  may  be  displaced  as  described  under  anomalies  of 
location. 

A  few  cases  have  been  described  in  which  three  kidneys  were  said 
to  be  present.  Most  of  them  were  probably  cases  in  which  one  kidney 
had  become  subdivided  into  two  portions  by  a  deep  furrow  extending 
entirely  through  it,  the  two  portions  becoming  somewhat  displaced 
from  each  other,  and  the  ureter  from  each  soon  uniting  to  form  a 
common  ureter.  Cheyne  {Lancet,  1899,  vol.  i,  p.  215),  however,  de- 
scribes a  case  of  a  woman  on  whom  he  operated  for  a  movable  tumour 
situated  to  the  right  of  the  middle  line.  Upon  opening  the  abdomen  the 
tumour  was  found  to  be  a  movable  third  kidney  with  its  own  ureter 
and  blood  supply.  It  lay  near  the  pelvic  brim  from  3  to  4  inches  from 
the  normal  riglit  kidney,  which  was  present.  A  left  kidney,  some- 
what smaller  than  normal,  was  present  in  the  usual  location. 

Anomalies  of  Location. — The  kidney  may  occupy  any  position  from 
the  normal  above,  to  within  the  pelvis  below.  Both  kidneys  may  oc- 
cupy the  same  side  of  the  body,  lying  one  above  the  other.  The  ureter 
of  the  misplaced  kidney  usually  crosses  over  to  its  proper  side  where 
it  enters  the  bladder  at  the  normal  place.  The  most  common  mis- 
placement is  at,  or  near,  the  brim  of  the  pelvis,  over  the  sacro-iliac 
joint,  or  just  within  the  pelvis.  Of  76  collected  cases  of  pelvic  mis- 
placement, the  right  kidney  was  misplaced  12  times,  and  the  left  64 
times.  The  ureter  is  shorter  than  normal,  according  to  the  degree 
of  misplacement,  but  enters  the  bladder  at  the  usual  point.  The  blood 
supply  is  derived  from  the  aorta  near  its  point  of  bifurcation,  or  from 
one  or  the  other  iliac  arteries.  The  kidney  is  usually  fixed,  and  some- 
what flattened  from  before  backward.  When  in  the  pelvis,  the  kidney 
may  be  the  cause  of  dystocia  by  preventing  the  engagement  of  the 
head.  In  such  a  case,  Cragin  did  a  vaginal  nephrectomy  under  the 
supposition  that  it  was  a  tumour  causing  the  dystocia.     Goulliund 


THE  FEMALE  URINARY  APPARATUS  751 

operated  on  a  pelvic  kidney  under  the  mistaken  diagnosis  of  in- 
terstitial salpingitis.  Misplaced  kidneys  may  be  the  seat  of  pathologic 
changes. 

Dartigues  operated  on  what  he  supposed  to  be  a  cyst  of  the  mesen- 
tery, but  found  a  case  of  nephropyosis  in  a  kidney  misplaced  in  the 
mesentery  of  the  small  intestine.  Such  cases  have  only  been  diagnosti- 
cated at  or  after  the  operation,  but  in  ail  cases  of  unusual  tumours  in 
the  pelvis  or  about  the  pelvic  brim,  the  possibility  of  a  misplaced  kid- 
ney should  be  considered.  In  misplaced  kidney,  the  adrenal  does  not 
usually  accompany  the  kidney  but  remains  in  its  normal  location. 

Anomalies  of  Form. — The  kidney  may  retain  its  foetal  lobulated 
form,  deep  fissures,  often  extending  to  the  pelvis,  separating  the  lobules. 

The  most  important  anomaly  of  form  is  the  "  fused  "'  kidney.  In 
this  condition  the  two  organs  are  united,  the  degree  of  union,  or 
fusion,  varying  from  the  simple  horseshoe  kidney  to  almost  com- 
plete fusion  into  one  organ.  In  the  variety  called  "  horseshoe  "  kidney, 
the  two  organs  lie  one  on  either  side  of  the  vertebrae,  their  lower  j^oles 
being  connected  by  a  band  of  tissue  called  the  isthmus,  which  extends 
across  the  vertebra  in  front  of  the  aorta  and  vena  cava.  The  isthmus 
may  be  composed  simply  of  a  band  of  connective  tissue,  or  it  may 
contain  kidney  tissue.  It  may  be  quite  long,  or  the  lower  poles  may 
be  fused  directly  together,  in  which  latter  case  a  connective-tissue 
septum  usually  separates  the  kidney  elements  belonging  to  one  organ 
from  those  belonging  to  the  other.  The  pelves  are  usually  directed 
more  anteriorly  than  normally,  and  the  ureters  pass  in  front  of  the 
isthmus.  Earely,  the  isthmus  extends  between  the  upper  poles  instead 
of  the  lower. 

The  fused  organs  may  both  lie  on  the  same  side  of  the  body,  in 
which  case  the  lower  of  the  two  is  the  misplaced  organ.  The  lower 
pole  of  one  fuses  with  the  upper  pole  of  the  other,  with  the  pelves 
looking  in  opposite  directions  or  in  the  same  direction.  Almost  all 
degrees  of  fusion  may  take  place,  but  the  pelves  usually  remain  com- 
pletely separate  and  distinct,  each  having  its  own  pyramids  and  tubules 
supplying  it,  and  each  having  its  own  ureter.  One  half  of  a  fused  organ 
may  be  the  seat  of  pathologic  changes,  while  the  other  half  remains 
normal,  a  fact  of  considerable  surgical  importance.  Abnormities  in 
the  blood  supply  are  almost  always  present.  Fusion  does  not  appear  to 
predispose  to  disease.  According  to  McMurrick  (International  Journal 
of  Surgery,  1898,  vol.  xi,  p.  335),  40  per  cent  of  the  fused  organs  were 
on  the  right  side  and  60  per  cent  on  the  left;  78  per  cent  occurred  in 
men  and  22  per  cent  in  women. 

Under  the  anomalies  of  form,  may  be  mentioned  the  "  suppressed," 
or  congenitally  small  kidney.  In  this  case  the  kidney  has  been  arrested 
in  its  growth  so  that  often  but  a  remnant  of  the  organ  is  found.  A 
"  suppressed  "  kidney  may  secrete  urine  of  normal  composition,  but 
in  quantity  insufficient  to  maintain  life  should  the  opposite  organ  re- 
quire removal. 


752  ^  TEXT-BOOK   OF   GYNECOLOGY 

Movable  Kidney. — The  kidneys,  although  classed  as  fixed  organs, 
move  up  and  down  with  respiration,  the  normal  range  of  motion  vary- 
ing from  2  to  5  centimetres  in  a  longitudinal  direction.  As  a  rule, 
the  normal  kidney  can  not  be  palpated  through  the  intact  body  walls 
in  men,  but  in  women  the  right  can  be  distinctly  felt  in  a  majority  of 
the  cases,  and  the  left  in  a  much  smaller  proportion.  The  extent  to 
which  the  kidney  may  be  felt,  varies  from  the  lower  third  to  the  major 
portion.  It  is  best  sought  with  the  person  standing,  the  body  bent 
slightly  forward  so  as  to  thoroughly  relax  the  anterior  abdominal 
muscles.  The  volar  surfaces  of  the  fingers  of  one  hand  should  be 
pressed  firmly  against  the  loin  beneath  the  twelfth  rib,  while  those  of 
the  opposite  hand  are  crowded  upward  and  backward  beneath  the  costal 
arch  in  front.  While  the  person  takes  a  deep  breath,  the  kidney,  if 
palpable,  may  be  grasj)ed  between  the  two  hands.  A  kidney  that  can 
thus  be  felt  is  called  a  "  palpable  kidney."  A  kidney  may  be  "  pal- 
pable "  without  being  movable.  By  the  term  "  movable  kidney,"  is 
meant  one  which  is  not  onl}^  palpable,  but  which  likewise  possesses  a 
degree  or  range  of  motion  in  excess  of  the  normal.  There  are  all  degrees 
of  mobility  in  "  movable  kidney."  It  may  move  up  and  down  but 
slightly  in  excess  of  the  normal,  or  it  may  descend  as  low  as  the  true 
pelvis.  It  may  move  forward  beneath  the  costal  arch  as  far  as  the 
anterior  abdominal  wall,  or  it  may  be  moved  inward  to  considerably 
beyond  the  middle  line.  Most  English  writers  divide  this  subject 
into  "  movable  "  and  "  floating  "  kidney,  the  former  being  considered 
an  acquired,  the  latter  a  congenital  condition.  The  "  floating  "  kidney 
is  described  as  possessed  of  a  mesonephron  of  congenital  origin  which 
permits  of  a  Avide  range  of  motion.  As  yet  no  anatomic  facts  have  been 
presented  which  demonstrate  the  congenital  origin  of  a  mesonephron, 
consequently  the  condition  must  be  considered  one  of  degree  only,  and 
the  term  "movable"  kidney  will  here  be  used  for  all  degrees  of  mobility. 

Movable  kidney  is  a  very  common  condition,  but  statistics  based 
upon  dead-house  reports  are  very  misleading.  This  unreliability  of 
dead-house  statistics  is  due  mainly  to  two  reasons:  First,  the  condition 
rarely  plays  any  direct  part  in  the  cause  of  death,  and  consequently  is 
frequently  overlooked;  and,  secondly,  when  the  patient  assumes  the  re- 
cumbent position,  the  kidney  usually  returns  to  its  normal  location, 
and  the  post-mortem  solidification  of  the  perirenal  fat  limits  its  degree 
of  mobility.  AYe  therefore  turn  to  clinical  experience  to  determine  the 
frequency  of  this  condition.  Klister  examined  in  order  1,733  patients 
as  they  applied  to  him  in  private  practice,  and  found  44  eases  of  mov- 
able kidney.  There  were  828  men  with  4  cases,  or  0.48  per  cent,  and 
905  women  with  40  cases,  or  4.41  per  cent.  This  is  a  good  illustration 
of  the  general  average  in  a  surgical  practice.  In  an  exclusively  gyneco- 
logical practice,  the  percentage  is  much  higher,  as  not  far  from  20  per 
cent  of  such  eases  will  be  found  to  have  "  movable  "  kidney  (Edebohls). 

In  considering  the  etiology  of  movable  kidney,  two  facts  stand  out 
so  prominently  that  all  etiological  factors  must  be  consistent  therewith. 


THE   FEMALE  URINARY   APPARATUS  753 

These  are:  First,  the  proportion  of  women  affected  is  greatly  in  excess 
of  men;  secondly,  the  right  kidney  is  affected  much  more  frequently 
than  the  left.  In  667  cases  collected  by  Kuttner  {Berliner  klinische 
Wochenschrift,  1890,  Nos.  15-17)  584  subjects  were  women,  and  83  men. 
The  explanation  of  this  marked  predominance  of  women  over  men  is 
found  in  the  body  form.  The  upper  or  cephalic  portion  of  the  abdom- 
inal cavity  is  relatively  of  much  smaller  capacity  in  women  than  in 
men.  The  cavity  is  not  only  contracted  laterally,  but  from  before  back- 
ward as  well.  The  effect  of  this  is  to  displace  and  distort  the  organs 
occupying  this  zone  of  the  abdomen.  The  stomach  lies  in  a  more  longi- 
tudinal direction  and  the  pylorus  is  depressed.  The  liver  is  compressed 
from  before  backward,  thus  depressing  its  anterior  and  posterior  bor- 
ders. The  depression  of  the  posterior  border  crowds  the  right  kidney 
lower  and  tends  to  displace  or  tilt  the  superior  pole  in  an  anterior  direc- 
tion. The  increased  breadth  of  the  female  pelvis  gives  to  the  psoas 
muscles  a  more  oblique  direction  than  in  the  male.  This  condition 
produces  an  obliquity  in  the  sagittal  axis  of  the  kidney  so  that  the 
superior  pole  lies  nearer  the  middle  line  than  the  inferior.  The  rela- 
tion between  the  body  form  and  the  location  of  the  kidney  is  so  con- 
stant, that  by  dividing  the  length  of  the  body  from  the  suprasternal 
notch  to  the  upper  border  of  the  symphysis  pubis  by  the  least  circum- 
ference of  the  body,  an  "  index  "  will  be  found  from  which  it  may 
confidently  be  predicted  in  a  given  case  whether  the  kidney  will  be 
found  palpable  or  not.  The  formula  of  this  index  as  expressed  by  Becker 
and  Lennhoff  {Deutsche  medicinische  Wochenschrift,  1898,  Bd.  xxiv,  p. 

Kf^o^  ■        #11  distance  jugulo-symphysis     ^-,^^_-    ^^^^     rpr,^ 

508)  IS  as  follows: .; — ^-i ■ — t — ■ ? X  100  —  mcLex.     ine 

least  abdominal  circumference 

greater  the  index,  the  smaller  the  upper  zone  of  the  abdomen,  and 
vice  versa.  Therefore  the  greater  the  index,  the  lower  the  kidney  will 
be  found.  With  an  index  above  77,  the  kidney  is  almost  always  "  pal- 
pable," while  with  an  index  below  75,  it  is  the  exception  to  find  a  "  pal- 
pable "  kidney.  The  body  form  must,  therefore,  be  considered  the 
predisposing  factor  in  the  cause  of  "  movable  "  kidney,  and  explains  the 
predominance  of  movable  kidney  in  women  over  men. 

Etiology. — The  chief  determining  cause  is  mechanical  insult  to  the 
kidney.  Mechanical  influences  may  be  divided  into  internal  and  exter- 
nal, the  former  being  the  more  common  and  important.  By  internal 
mechanical  influences  are  meant  all  sudden  or  severe  muscular  strains, 
such  as  heavy  lifting,  wrenching  of  the  body  by  slipping  or  falling, 
straining  at  stool,  coughing,  twisting  and  turning  of  the  body,  in  fact 
any  muscular  action  that  produces  adduction  of  the  lower  movable  ribs 
and  thus  a  constriction  of  the  upper  zone  of  the  abdominal  cavity.  In 
body  forms  with  high  indices,  it  will  be  found  that  the  plane  corre- 
sponding to  the  least  abdominal  circumferences  cuts  the  distal  portion 
of  the  floating  ribs  in  women  and  passes  above  the  centre  of  the  kidney, 
particularly  the  right.  The  effoct,  therefore,  of  adduction  of  the  lower 
ribs  by  the  internal  mechanical  influences  above  mentioned,  is  to  bring 
49 


Y54  A  TEXT-BOOK  OP   GYNECOLOGY 

pressure  on  the  upper  portion  of  the  kidney  and  thus  depress  it.  In 
men^  the  before-described  jDlane  usually  passes  below  the  centre  of  the 
kidney,  so  that  constriction  at  this  level  tends  to  elevate  or  compress  the 
kidney. 

The  truth  of  the  above  statements  is  well  exemplified  by  the  statis- 
tics of  Kuster  {Archiv  filr  Minisclie  Chirurgie).  He  found  that  of  295 
cases  of  traumatic  subcutaneous  rupture  of  the  kidney,  93  per  cent 
were  in  men  and  only  8  per  cent  in  women,  while  of  84  cases  of  "  mov- 
able "  kidney  the  percentages  were  almost  reversed — namely,  94  per 
cent  in  women  and  only  6  ])er  cent  in  men. 

By  external  mechanical  influences  are  meant  injuries,  such  as  falls, 
sudden  jolts  of  the  body,  or  blows  about  the  region  of  the  kidney.  That 
an  injury  may  directly  produce  a  movable  kidney,  is  certain.  Harris 
has  seen  a  movable  kidney  in  a  man,  produced  by  his  being  thrown 
from  a  runaway  carriage,  and  a  case  in  a  woman,  produced  by  a  fall  on 
the  buttocks.  Cases,  however,  that  are  directly  and  solely  attributable 
to  a  single  injury  are  not  common.  Usually,  the  injury  but  directs  atten- 
tion, or  aggravates  somewhat,  a  kidney  already  more  or  less  movable. 

The  principal  reason  why  the  right  kidney  is  so  much  more  fre- 
quently movable  than  the  left  is,  unquestionably,  the  presence  on  the 
right  side  of  the  liver.  This  organ  forms  a  firm,  resisting  body  which 
transmits  all  force  from  above  directly  to  the  kidney,  and  prevents  it 
from  moving  in  any  direction  except  downward  and  forward.  The  left 
kidney  is  not  only  somewhat  more  firmly  fixed  in  its  location,  but  has 
above  it  only  the  small  spleen  and  the  soft  yielding  stomach. 

What  has  brought  about  the  body  form  of  the  female,  which  is  so 
favourable  to  the  occurrence  of  movable  kidney?  The  broader  hips,  of 
course,  are  a  sex  peculiarity.  The  narrow  contracted  waist,  however, 
is  an  acquired  condition  produced  by  artificial  constriction  which  has 
been  operative  for  innumerable  generations.  This  constriction  is  due, 
not  alone  to  the  corset,  but  to  the  tight  skirt  bands  as  well,  and  the 
latter  are  often  more  harmful  than  the  former,  as  is  shown  by  the  fact 
that  movable  kidney  is  not  uncommon  in  labouring  women  who  have 
never  worn  corsets  but  who  constantly  constrict  their  waists  with  tight 
skirt  bands.  According  to  Thomson  {Ediiiburgli  Medical  Journal,  De- 
cember, 1900),  however,  Trekaki,  of  Alexandria,  finds  that  42  per  cent 
of  Arab  women,  who  wear  no  corset,  girdle,  or  constriction  of  any  kind, 
have  a  freely  movable  kidney.* 

There  are  other  conditions  that  are  considered  by  some  authors  as 
instrumental  in  the  production  of  movable  kidney.  Foremost  among 
these  may  be  mentioned  pregnancy.  That  the  influence  of  pregnancy 
has  been  greatly  overestimated  is  apparent  when  we  learn  that  from 
30  to  50  per  cent  of  the  cases  occur  in  the  unmarried,  or  in  those  who 
have  never  borne  children.  In  188  cases  seen  and  collected  by  Harris, 
89  were  married,  83  were  single,  and  in  6  the  condition  was  not  stated. 
Of  the  married,  4  are  stated  never  to  have  borne  children.  Comby 
{British  Medical  Journal,  1898,  vol.  ii)  mentions  18  cases  in  children. 


THE  FEMALE   URINARY   APPARATUS 


755 


Two  were  aged,  respectively,  one  and  three  months,  6  were  between  one 
and  ten  years,  and  10  were  over  ten  years  of  age.  The  same  argument  is 
applicable  against  the  statement  that  laceration  of  the  perineum,  with 
prolapse  and  displacement  of  the  uterus,  is  a  material  factor  in  the 
causation  of  movable  kidney. 

The  relaxation  of  the  anterior  abdominal  wall  and  diminished  intra- 
abdominal tension  following  the  removal  of  large  abdominal  tumours 
and  fluid  accumulations,  are  supposed  to  favour  the  occurrence  of 
movable  kidney,  but  in  large  scrotal  hernige  in  men  and  in  umbilical 
hernias  in  women,  where  the  intra-abdominal  pressure  is  often  very 
much  reduced,  movable  kidney  is  not  common.  Absorption  of  the 
perirenal  fat,  as  occurs  in  wasting  diseases,  has  been  emphasized  par- 
ticularly by  Landau  as  an  etiological  factor.  As  it  is  inconsistent  with 
the  two  fundamental  facts  stated  above,  its  influence  must  be  consid- 
ered slight.  The  course  of  the  ureters  through  the  pelvis  is  too  much 
of  a  curve  and  too  much  "  slack  "  is  present,  as  shown  by  the  possi- 
bility of  uretero-ureteral  anastomosis,  for  the  kidneys  to  be  materially 
influenced  by  displacements  of  the  uterus  and  tubal  disease  drawing  on 
the  ureters. 

The  causes  of  movable  kidney,  then,  may  be  summarized  thus:  The 
principal  predisposing  cause  is  the  body  form.  Principal  determining 
cause:  repeated  internal  and  ex- 
ternal mechanical  influences  as 
defined  above.  Of  the  minor  in- 
fluences may  be  mentioned  gen- 
eral relaxation  of  the  abdomi- 
nal walls  and  kidney  attach- 
ments following  distention,  wast- 
ing diseases,  or  enervating  condi- 
tions. 

The  pathologic  anatomy  of 
movable  kidney  varies  some- 
what according  to  the  degree  of 
mobility.  Three  degrees  of  mo- 
bility may  be  described:  1.  That 
in  which  the  major  portion  of 
the  kidney  is  palpable;  2.  That 
in  which  the  kidney  descends  so 
low    that    the    hands    may    be 

brought  together  above  it  (Fig.  p,e  306.—'-  The  kidney  deseeDds  so  low  that 
306);  3.  That  in  which  the  range  the  hands  may  be  brought  together  above 

of  motion  is  so  great  that  the  kid-  it."-HARuis. 

ney  may  descend  to  the  brim  of 

the  pelvis,  move  forward  to  the  anterior  abdominal  wall,  or  be  moved 

inward  beyond  the  middle  line  (Fig.  307).     In  the  first  and  second 

degrees,   the   kidney   moves   up   and    down    in   the    connective-tissue 

.space  formed  anteriorly  by  the  prerenal,  and  posteriorly  by  the  retro- 


756 


A   TEXT-BOOK  OF  GYNECOLOGY 


y 


Fig.  307. — "  The  kidney  may  descend  to  the 
briin  of  the  pelvis." — Haekis  (page  755). 


renal,  fascia.  The  perirenal  fat  which  varies  much  in  quantity  moves 
mostly  with  the  kidney.  As  the  renal  fascia  passes  between  the  adrenal 
and  the  kidney,  the  former  remains  fixed  and  does  not  move  with 

the  latter.  In  the  third  degree, 
the  perirenal  fat  is  often  much 
less  in  amount  and  may  almost 
entirely  disappear.  As  the  kid- 
ney moves  anteriorly,  it  carries 
with  it  the  prerenal  fascia  and 
the  peritoneum,  so  that  these 
structures  gradually  surround  the 
kidney  more  and  more,  forming 
with  the  vessels  and  ureter  at  the 
hilum  a  pedicle  or,  as  it  is  some- 
times called,  a  mesonephron.  The 
peritoneum  is  not  firmly  attached 
to  the  kidney  as  in  normal  intra- 
peritoneal organs,  but  loosely 
fixed  thereto,  being  separated 
from  it  by  the  prerenal  fascia  and 
subperitoneal  tissue.  The  renal 
vessels  are  often  considerably 
lengthened.  Legueu  describes 
vessels  that  were  11  and  13  centi- 
metres long.  The  kidne}^  moves  through  an  arc  of  a  circle  of  which 
the  vessels  form  the  radius  and  their  point  of  origin  the  centre. 
The  range  of  motion  is  therefore  limited  by  the  length  of  the  vessels. 

The  large  majority  of  mov- 
able kidneys  belong  to  the  first 
and  second  degrees.  Those  in 
which  a  so-called  mesonephron 
is  present  are  quite  rare.  At 
times  the  kidney,  instead  of 
moving  up  and  down  in  a  longi- 
tudinal direction,  has  its  supe- 
rior pole  tilted  forward,  the  or- 
gan moving  in  an  antero-poste- 
rior  direction,  and  approaching 
the  surface  just  below  the  edge 
of  the  liver  between  this  and 
the  transverse  colon  (Fig.  308). 
Again,  the  kidney  may  turn 
about  an  antero-posterior  axis 
so  that  the  hilum  looks  upward, 
and  the  superior  pole  may  even 
occupy  a  lower  level  than  the      fig.  308.-"  At  times  the  kidney  .  .  .  has  its 

inferior.       More    or    less    of    the  superior  pole  tilted  forward." — Hakkis. 


THE   FEMALE   URINARY   APPARATUS 


757 


upper  portion  of  the  ureter  usually  moves  with  the  kidney,  and  there  is 
often  a  marked  tendency  for  the  ureter  to  become  sharply  flexed  or 
kinked  at  the  junction  of  the  movable  with  the  fixed  portion.  This 
kinking  of  the  ureter  may  interrupt  temporarily  the  flow  of  urine  pro- 
ducing distention  of  the  pelvis  and  leading,  eventually,  to  the  for- 
mation of  an  intermittent  nephrydrosis  (Fig.  309).  The  renal  vessels 
may  also  be  sharply  flexed  so  as  to  interfere  with  the  blood  supply 
to  the  kidney.  A  movable  kidney  may  acquire  new  attachments  to 
neighbouring  organs,  as,  for  instance,  to  the  duodenum,  the  under 
surface  of  the  liver,  the  colon,  or 
the  small  intestine.  Such  attach- 
ments may  limit  its  mobility  or 
prevent  its  being  returned  to  its 
normal  location.  Movable  kidney 
is  frequently  associated  with  de- 
scent of  other  abdominal  organs 
such  as  the  stomach,  liver,  colon, 
or  small  intestine.  By  some  au- 
thors, it  is  considered  simply  a 
part  of  a  general  visceral  ptosis 
which  is  described  under  the 
name  of  G-lenard's  disease.  Such, 
however,  is  not  the  case,  as  mov- 
able kidney  is  often  found  unac- 
companied by  marked  displace- 
ment of  any  other  abdominal 
■organ.  Dilatation  of  the  stom- 
ach has  been  so  frequently  found 
in  connection  with  movable  kid- 
ney, that  a  dependent  relation  is 
claimed,  based  upon  the  fact  that 
the  kidney  (right)  in  its  move- 
ments may  compress,  drag  upon,  or  so  kink  the  duodenum,  as  to 
interfere  with  the  proper  emptying  of  the  stomach,  or  through  nervous 
action  disturb  stomachic  digestion.  Frank  {British  Medical  Journal, 
1895,  vol.  ii,  p.  895)  mentions  a  case  of  movable  kidney  so  attached  to 
the  duodenum  that  the  intestine  would  be  kinked  whenever  the  kidney 
moved  out  of  place.  The  characteristic  changes  of  dilatation  and 
chronic  catarrh  are  often  found  in  the  stomach.  In  left-sided  movable 
kidney,  the  spleen  may  also  be  abnormally  movable,  but  it  usually 
retains  its  proper  location. 

Symplomatolofiy . — In  a  systematic  examination  of  patients,  one  fre- 
quently finds  movable  kidneys  that  have  given  rise  to  no  symptoms 
whatever,  and  whose  presence  was  unknown  or  unsuspected  until  dis- 
covered incidentally  during  the  examination.  On  the  other  hand  one 
sees  patients  whose  lives  are  made  miserable  by  a  train  of  symptoms 
produced  by  a  moval)le  kidney.     Pjetween  these  extreines  all  degrees 


Fig.  309. — "  This  kinking  of  the  ureter  may 
interrupt  temporarily  the  flow  of  urine, 
.  .  .  leading  to  the  formation  of  an  inter- 
mittent nephrydrosis." — Harris. 


758  A  TEXT-BOOK  OF   GYNECOLOGY 

will  be  found.  The  number  and  severity  of  the  symptoms  do  not  neces- 
sarily depend  upon  the  degree  of  motion  present,  as  there  may  be  more 
suffering  in  one  case  with  motion  of  the  first  degree  than  in  another 
with  motion  of  the  third  degree.  It  is,  at  times,  difficult  to  state  why 
one  patient  should  suffer  so  much  and  another  so  little.  In  sudden  dis- 
placement or  acute  dislocation  of  the  kidney,  the  result  of  an  injury, 
there  is  always  pain  in  the  side  affected,  and  the  patient  often  states 
that  a  feeling  as  if  something  had  given  way  in  the  side  was  experi- 
enced. The  pain  may  be  quite  severe,  and  be  attended  by  nausea  or 
vomiting.  There  may  be  a  frequent  desire  to  urinate  and,  at  times,  a 
little  blood  in  the  urine.  That  side  will  be  tender  to  touch,  and,  on 
examination,  the  kidney  may  be  felt  in  its  dislocated  position.  The 
kidney  may  be  found  dislocated  forward  along  the  under  surface  of  the 
liver,  or  downward  behind  the  ceecum,  or  inward  toward  the  middle 
line.  It  may  return  spontaneously  to  its  normal  location  or  appear 
somewhat  fixed,  requiring  gentle  manipulation  to  reduce  it.  After 
reduction,  the  symptoms  quickly  subside.  After  an  acute  dislocation, 
the  kidney  may  regain  its  former  fixed  condition,  or  it  may  remain 
permanently  more  or  less  movable.  The  symptoms  attributable  to  mov- 
able kidney  may  be  arranged  under  four  heads:  Pain;  disturbances  of 
the  urinary  organs;  disturbances  of  the  gastro-intestinal  tract;  dis- 
turbances of  the  nervous  system.  The  pain  is  located  in  the  lumbar  re- 
gion just  below  the  twelfth  rib,  or  anteriorly  extending  from  the  costal 
border  down  the  side  toward  the  inguinal  region  or  the  bladder.  It 
may  be  located  over  the  region  of  the  appendix,  and  Edebohls  has  par- 
ticularly directed  attention  to  the  association  of  appendicitis  with 
movable  kidney.  The  pain  may  be  quite  acute,  or,  more  commonly, 
a  dull  aching  or  a  dragging  feeling  which  is  aggravated  by  standing, 
walking,  or  lifting. 

Of  the  urinary  symptoms,  frequent  urination  is  the  most  common. 
It  is  most  marked  when  standing,  and  usually  disappears  at  night  or 
when  lying  down.  The  desire  to  urinate  frequently  may  be  periodic. 
Harris  had  a  case  of  a  woman  with  a  movable  right  kidney  who,  at 
irregular  intervals,  would  have  severe  attacks  of  painful,  frequent 
urination,  lasting  several  hours.  She  was  permanently  relieved  by 
fixing  the  kidney. 

Gastric  symptoms  are  among  the  most  common  with  which  these 
patients  are  affected.  They  are  the  usual  symptoms  noted  in  gastric 
dilatation  and  chronic  catarrhal  gastritis,  such  as  pain  and  distress 
after  eating,  eructations,  nausea,  and,  at  times,  vomiting.  There  is 
tenderness  on  pressure  in  the  epigastric  region,  and  the  abdominal  aorta 
pulsates  so  markedly  at  times  that  one  may  be  led  to  suspect  an 
aneurism.  Ffitterer  calls  attention  to  a  bruit  sometimes  heard  over  the 
renal  artery,  which  he  considers  due  to  a  partial  kinking  of  that  vessel. 
Earely,  jaundice  has  been  noted,  caused  probably  by  the  kidney  draw- 
ing on  the  hepatico-duodenal  ligament.  Constipation  is  the  rule  and 
flatulence  common.     In  connection  with  the  nervous  system,  we  find 


THE  FEMALE  URINARY   APPARATUS  759 

dizziness  very  common,  headaches,  frontal  or  occipital,  and,  at  times, 
all  the  vague  nervous  disturbances  of  hysteria  and  neurasthenia. 
Sometimes,  the  mental  state  is  one  of  depression  or  despondency 
amounting  almost  to  melancholia.  Patients  with  movable  kidneys  are 
liable  to  acute  attacks,  at  irregular  intervals,  which  are  quite  charac- 
teristic. They  consist  of  acute  pain  in  the  region  of  the  kidney  often 
extending  down  the  ureter  to  the  bladder,  with  frequent,  scanty  urina- 
tion, and  nausea  or  vomiting.  These  attacks  may  be  very  severe  and 
may  simulate  renal  colic  due  to  calculus.  They  are  called  Dietl's  crises 
and  are  probably  due  to  a  sudden  twisting  of  the  pedicle,  causing  a 
kinking  of  the  renal  vessels  and  ureter  and  a  drawing  on  the  renal 
nerves.    They  disappear  on  returning  the  kidney  to  its  normal  position. 

Many  of  the  foregoing  symptoms  will  be  found  aggravated  during 
menstruation,  and  the  kidney  at  this  time  is  usually  somewhat  larger 
and  more  tender  to  pressure.  It  is  not  to  be  expected  that  all  these 
symptoms  will  be  present  in  any  one  case,  but  the  cases  may  usually 
be  grouped  according  to  the  prominence  of  particular  symptoms.  We 
thus  find  that  in  some  cases  the  symptoms  are  referred  principally  to 
the  urinary  organs,  in  others  to  the  gastro-intestinal  tract,  and  that 
in  yet  a  third  group  the  nervous  symptoms  are  the  most  prominent.  It 
should  also  be  remembered  that  movable  kidney  is  frequently  found 
associated  with  other  conditions,  such  as  lacerations  of  the  pelvic  floor, 
uterine  displacements,  tubal  and  ovarian  diseases,  chronic  appendicitis, 
gastric  disturbances  due  to  other  causes,  visceral  ptosis,  anaemia,  etc., 
so  that,  in  individual  cases,  judicious  discrimination  is  often  necessary 
in  assigning  to  each  condition  its  proper  influence  in  determining  the 
symptoms  present.  Owing  to  the  relations  of  the  right  kidney  to  the 
duodenum  and  bile  tracts,  gastric  symptoms  are  usually  more  pro- 
nounced when  the  right  kidney  is  involved  than  when  the  left  alone 
is  movable.  The  diagnosis  of  movable  kidney  must  always  rest  on  the 
findings  of  a  physical  examination.    (See  Physical  Examination.) 

The  treatment  of  movable  kidney  is  palliative  and  operative.  Pallia- 
tive treatment  consists  of  the  use  of  abdominal  supports,  pads  and 
trusses,  massage  and  symptomatic  treatment.  In  patients  with  lax, 
dependent  abdomens,  with  or  without  general  visceral  ptosis,  the  use  of 
a  well-fitting,  firm,  abdominal  supporter  is  often  followed  by  marked 
relief.  In  those  cases  in  which  the  superior  pole  of  the  kidney  tilts 
forward,  and  the  kidney  approaches  the  anterior  wall  below  the  edge 
of  the  liver,  a  properly  applied  pad  may  materially  aid  in  retaining  it  in 
position,  but,  in  the  majority  of  cases,  in  which  the  kidney  has  a  down- 
ward movement,  it  is  practically  impossible  to  retain  it  in  place  by  pad 
or  truss,  and  most  observers  are  agreed  that  the  use  of  mechanical 
appliances  is  here  without  material  benefit.  Massage  has  been  recom- 
mended particularly  by  Kumpf  with  the  idea  that  thereby  a  retraction 
of  the  peritoneum  around  the  kidney  may  be  brought  about,  thus  fixing 
it  again  in  place.  Tliat  such  result  is  ever  obtained  is  more  than 
doubtful.     'IFowever,  massage  rnay  be  of  benefit  in  restoring  tone  to  a 


760  ^  TEXT-BOOK  OP  GYNECOLOaY 

relaxed  abdominal  wall,  in  overcoming  constipation,  and  in  improving 
digestion,  thus  relieving  many  of  the  symptoms  accompanying  this  con- 
dition. 

Symptomatic  treatment  should  deal  with  the  condition  of  the 
stomach,  the  constipation,  the  ansemia,  the  nervous  symptoms,  etc.  In 
this  manner,  all  associated  or  incidental  conditions  may  be  relieved, 
leaving  such  as  are  due  directly  to  the  movable  kidney.  A  movable 
kidney  can  be  permanently  restored  to  its  normal  location  by  operation 
only.  Not  all  cases,  however,  require  operation.  Operation  is  advis- 
able: 1.  When  distinct  symptoms  are  present  which  are  unrelieved  by 
mechanical  or  symptomatic  treatment;  2.  Where  secondary  changes 
in  the  kidney  are  present,  due  to  the  mobility  (nephrydrosis,  nephritis). 
In  those  cases  associated  with  general  enteroptosis,  an  operation  on 
the  kidney  should  be  followed  by  mechanical  support  of  the  abdominal 
wall.  Those  cases  which  are  relieved  by  pads  or  trusses  should  be 
given  the  option  of  an  operation  with  release  from  the  annoyances  of 
mechanical  appliances.  The  gravity  of  the  operation  in  uncomplicated 
cases  is  slight,  the  mortalit}^  being  from  1  to  2  per  cent — 374  cases  with 
4  deaths  (Albarran).  Relief  from  symptoms  is  most  marked  in  those 
cases  in  which  pain,  and  urinary  and  gastric  disturbances,  are  most 
prominent.  In  such,  the  results  are  usually  very  gratifying.  In  the 
distinctly  nervous  type,  much  less  can  be  promised,  as  such  patients 
are  frequently  confirmed  neurasthenics  or  hysterical,  and  such  states 
are  likely  to  persist. 

However,  if  it  can  be  shown  that  the  nervous  state  has  its  origin 
in  the  movable  kidney,  much  good  may  result  from  the  operation.  The 
operation  is  that  of  nephropexy  or  fixation  of  the  kidney.  (See  Opera- 
tion on  the  Kidney.) 

Anomalies  of  the  Ureters. — The  most  common  anomaly  of  the 
ureter  is  duplication.  This  may  occur  unilaterally  or  bilaterally. 
The  second  ureter  may  extend  from  the  kidney  to  the  bladder,  open- 
ing into  this  organ  usually  a  little  above  the  normal  opening,  or  the 
supernumerary  ureter  may  join  its  fellow  at  any  point  along  its 
course.  It  may  terminate  at  the  bladder  in  a  blind  tube  which,  as 
it  becomes  distended  with  urine,  may  project  into  the  bladder  as  a 
cystic  pouch.  This  pouch  may  even  obstruct  the  opening  of  the  nor- 
mal ureter  and  thus  give  rise  to  a  nephrydrosis.  The  ureters  may 
open  abnormally  into  the  bladder,  both  ureters  opening  on  the  same 
side.  A  ureter  may  open  near  the  internal  orifice  of  the  urethra  or 
even  into  the  urethra  or  the  vestibule  alongside  of  the  meatus  uri- 
narius.  In  the  latter  two  cases,  permanent  incontinence  of  urine 
will  be  present,  as  the  urine  will  escape  continuously  from  the  open 
ureter,  and  a  surgical  operation,  having  for  its  object  the  implanta- 
tion of  the  ureter  into  the  bladder,  will  be  necessary  to  correct  the 
condition. 

Stricture  of  the  ureter  may  result  from  cicatricial  contraction  fol- 
lowing internal  trauma  due  to  the  passage  of  a  stone ;  to  laceration 


THE  FEMALE   URINARY   APPARATUS  761 

from  overstretching  of  the  body,  and  to  injury  from  external  vio- 
lence. The  contraction  leads  to  dilatation  of  the  ureter  (hydro-ureter) 
above  the  seat  of  the  obstruction  and  to  the  development  of  a  nephro- 
cystosis  (g.  v.). 

The  latter  condition  usually  first  directs  attention  to  the  possi- 
bility of  a  stricture  which  may  then,  at  times,  be  located  by  means  of 
the  ureteral  bougie.  Attempts  have  been  made,  and  with  some  suc- 
cess, to  dilate  ureteral  strictures  by  passing  bougies  as  in  urethral 
strictures.  Should  this  not  succeed,  an  operation  may  be  necessary. 
The  ureter  may  be  reached  through  an  extended  oblique  incision,  the 
peritoneum  being  raised  up  and  carried  inward.  The  stricture,  if  it  is 
a  narrow  one,  may  be  divided  longitudinally  and  stitched  transversely 
after  the  manner  of  the  Heineke-Mikulicz  operation  on  the  pylorus 
(Fenger)  ;  or  the  stricture  may  be  resected,  the  upper  end  of  the 
lower  portion  of  the  ureter  ligated,  a  small  slit  made  in  the  canal  just 
below  the  ligature,  and  the  lower  end  of  the  upper  portion,  which 
has  been  slit  up  slightly,  invaginated  into  the  lower  portion  through 
the  slit  in  the  side  and  retained  by  fine  catgut  stitches  (Van  Hook). 

Calculi  may  lodge  in  the  ureter  in  their  passage  from  the  kidney. 
The  points  at  which  lodgment  most  frequently  takes  place  are  at  the 
contracted  portion  just  below  the  pelvis,  at  the  point  where  the  ureter 
curves  to  dip  into  the  pelvic  cavity,  and  just  before  it  enters  the  blad- 
der. When  a  stone  lodges,  it  interferes  more  or  less  with  the  free 
passage  of  the  urine  along  the  canal,  and  the  usual  changes  take  place 
above  the  seat  of  the  obstruction.  The  stone  may  ulcerate  through 
the  walls  of  the  canal  and  materially  increase  in  size  in  the  little 
pocket  which  it  forms.  Harris  has  seen  such  a  stone  lying  at  the 
brim  of  the  pelvis  and  measuring  over  3  centimetres  in  diameter. 
There  are  no  characteristic  symptoms  of  ureteral  stone.  A  history 
of  acute  pain  or  "colic,"  incident  to  the  passage  of  the  stone  from 
the  kidney  to  its  place  of  lodgment,  might  be  elicited  and  the  fact 
that,  following  such  an  attack,  no  stone  had  been  passed  might  sug- 
gest the  possibility  of  one  remaining  lodged  in  the  ureter,  particularly 
if  symptoms  of  renal  enlargement  appeared  soon  after.  Very  rarely, 
a  stone  in  the  abdominal  portion  of  the  ureter  has  been  palpated 
through  the  abdominal  wall.  Those  lodged  in  the  lower  portion  of 
the  canal  have  frequently  been  felt  through  the  vagina.  Usually,  the 
stone  is  discovered  by  passing  ureteral  bougies  either  from  below  or 
above,  while  endeavouring  to  discover  the  cause  of  obstruction  in 
nephrocystosis.  A  stone  lodged  in  the  upper  end  of  the  ureter  has 
been  dislodged  or  pushed  back  into  the  kidney  by  the  ureteral  bougie. 
\¥hen  lodged  fartlier  down,  its  passage  into  the  bladder  has  been 
facilitated  by  injecting  sterile  oil  through  a  ureteral  catheter  below 
the  stone  (Kolisher.  From  the  lower,  or  vaginal,  portion  of  the 
ureter,  stones  have  boon  removed  through  an  incision  from  the 
vagina,  and  when  in  the  bladder  wall,  by  dilating  the  ureteral  open- 
ing through  the  cystoscoy)e  or  a  suprapubic  opening.     When  situated 


762  A  TEXT-BOOK  OF  GYNECOLOGY 

in  the  abdominal  portion,  it  may  be  removed  through  the  extended 
oblique  incision  mentioned  under  Operations  on  the  Kidney.  The 
ureter  should  be  incised,  the  stone  removed,  and  the  incision  stitched 
with  fine  catgut.  If  unable  to  close  the  ureter,  it  may  be  left  open,  a 
packing  of  gauze  in  either  case  being  placed  down  to  the  opening  to 
guard  against  leakage. 

In  case  of  injury  to  the  ureter,  such  as  accidental  puncture  or 
incision  during  operations  within  the  pelvis,  the  unilateral  wound 
should  be  closed  at  once  by  fine  catgut  stitches.  If  completely  divided, 
an  immediate  anastomosis  should  be  made  after  the  method  of  Van 
Hook  (see  Strictures  of  the  Ureter),  or  if  near  the  bladder,  the 
proximal  end  should  be  reimplanted  in  the  bladder  at  the  most  con- 
venient point.  In  case  neither  of  these  procedures  is  possible,  it  may 
be  necessary,  as  a  last  resort,  to  implant  the  ureter  into  the  bowel 
and  run  the  risk  of  an  ascending  infection  of  the  kidney,  or  to  bring 
the  end  to  the  surface  at  some  point  leaving  a  permanent  fistula,  or  to 
remove  the  corresponding  kidney.  Fortunately,  owing  to  the  success 
of  ureteral  anastomosis,  these  latter  alternatives  will  seldom  be  ne- 
cessary. 

Nephrocystosis. — If  the  escape  of  urine  from  the  kidney  is  inter- 
rupted, completely  or  incompletely,  for  a  sufficient  length  of  time,  by 
any  cause  acting  upon  the  excretory  channels,  dilatation  of  the  pelvis 
and  calyces  of  the  kidney  results,  producing  the  general  condition  of 
nephrocystosis  (cystonephrosis).  This  condition  may  be  subdivided 
into  nephrydrosis  (uronephrosis,  hydronephrosis)  when  the  fiuid  con- 
tained in  the  dilated  pelvis  is  urine  or  modified  urine;  and  nephro- 
P3^osis  (pyonephrosis)  when  the  additional  element  of  infection  is 
present  with  the  formation  of  pus. 

Nephrydrosis  may  be  congenital  or  acquired.  The  congenital  vari- 
ety may  be  unilateral  or  bilateral.  When  bilateral,  the  child  is  not 
viable,  and  hence  is  not  a  subject  for  surgical  relief;  when  unilateral, 
the  condition  is  perfectly  compatible  with  life.  The  cause  of  the 
neijhrydrosis  is  usually  some  error  of  development  such  as  double 
ureter,  one  or  both  of  which  may  be  imperforate  or  stenosed,  or  im- 
perforation  of  a  single  ureter.  The  ureter  may  open  at  some  abnor- 
mal point  such  as  the  vestibule,  vagina,  urethra,  uterus  or  tubes,  in 
which  case  the  orifice  is  apt  to  be  small  and  contracted  and  the  ureter 
dilated  above  it.  The  ureter  may  enter  the  pelvis  of  the  kidney  so 
obliquely,  or  in  such  an  abnormal  manner,  as  to  lead  to  a  valve  forma- 
tion interrupting  the  free  escape  of  urine  from  the  pelvis  into  the 
ureter.  The  ureter  may  be  sharply  fiexed  by  a  malposition  of  the 
kidney  or  compressed  from  without  by  an  abnormal  or  anomalous 
renal  artery. 

As  a  result  of  some  of  these  abnormities  the  dilatation  may  be 
present  at  birth,  thus  being  strictly  congenital.  In  other  conditions, 
as  for  instance  valve  formation  at  the  uretero-pelvic  junction,  the 
nephrydrosis  may  not  develop  to  a  perceptible  degree  until  many  years 


THE  FEMALE   URINARY   APPARATL'S  763 

after  birth  or  in  adult  life.  While  in  these  cases  the  cause  of  the 
dilatation  is  of  congenital  origin,  their  late  development  makes  it  bet- 
ter to  classify  them,  at  least  clinically,  under  the  head  of  acquired 
nephrydrosis.  The  most  common  cause  of  acquired  dilatations  is 
pressure  on  the  ureter  in  its  course  through  the  small  pelvis.  This 
may  be  due  to  carcinoma  of  the  uterus,  particularly  of  the  cervix,  to 
intraligamentous  fibromyomata  or  other  tumours  of  the  small  pelvis, 
or  to  the  pregnant  uterus  compressing  the  ureter  at  the  pelvic  brim. 
(Olshausen,  Sammlung  Jclmische  Vortrdge,  1892.) 

Displacements  or  prolapse  of  the  unenlarged  uterns  seldom  pro- 
duce obstruction  of  the  ureter.  Epitheliomata  or  other  tumours  of 
the  bladder,  if  located  near  the  ureteral  orifice,  may  be  the  cause  of 
obstruction.  Internal  obstruction  of  the  ureter  may  be  due  to  the 
lodgment  of  a  calculus;  to  cicatricial  contraction,  the  result  of  an 
injury  inflicted  by  the  passage  of  a  calculus  or  the  uric-acid  infarcts 
of  early  infancy  (Bernard);  or  to  strictures  the  result  of  external 
trauma  or  of  tuberculosis  of  the  ureter. 

An  interesting  and  important  cause  of  nephrydrosis  is  movable 
kidney  (Landau).  Harris  has  seen  a  t}^ical  case  of  intermittent 
nephrydrosis  of  small  size,  due  to  a  movable  kidney  kinking  sharply 
the  upper  end  of  the  ureter,  also  one  due  to  a  "  Schniir "'  lobe  of  the 
liver  displacing  the  kidney  and  kinking  the  ureter.  Both  were  com- 
pletely relieved  by  operative  correction  of  the  position  of  the  kidney. 
Not  all  cases  of  intermittent  nephrydrosis,  however,  are  due  to  mov- 
able kidneys,  as  certain  valvular  formations  about  the  uretero-pelvic 
orifice  and  other  conditions,  not  always  readily  explainable,  may  per- 
mit the  irregular  or  periodic  evacuation  of  the  sac.  The  fundamental 
factor  in  all  cases  of  nephrydrosis  is  an  obstruction  to  the  escape  of 
urine  from  the  pelvis  of  the  kidney.  This  obstruction,  as  has  been 
shown,  may  vary  much  in  its  nature  and  location. 

The  pailiologic  changes  begin  at  the  point  of  obstruction  and  extend 
centrad.  Thus,  if  the  obstruction  is  located  at  the  lower  ureteral 
orifice  or  in  the  bladder,  the  entire  ureter  will  be  found  dilated;  if  the 
obstruction  is  located  along  the  course  of  the  ureter,  only  that  por- 
tion lying  above  or  centrad  of  it  will  take  part  in  the  dilatation; 
while  if  the  obstruction  is  at  the  uretero-pelvic  junction  the  ureter 
will  not  be  involved.  There  may  be  multiple  points  of  obstrnction 
with  sacciform  dilatations  between  them.  In  enlarging,  the  ureter 
becomes  thickened  and  elongated  and  assumes  a  curved  or  serpentine 
course.  The  upper  part  is  particularly  prone  to  assume  an  S-shaped 
curve  (Albarran)  which  may  become  secondarily  kinked  or  com- 
pressed by  the  enlarging  pelvis.  The  dilatation  of  the  pelvis  soon 
extends  to  the  calyces  (Fig.  310).  The  pyramids  gradually  become 
compressed  and  smaller,  and  eventually  are  almost  entirely  effaced. 
Occasionally,  the  calyces,  instead  of  forming  a  part  of  the  general 
pelvic  enlargement,  present  fingerlike  prolongations.  The  secreting 
portion  of  the  kidney  becomes  flattened  and  thinned  out,  resting  as  a 


764 


A   TEXT-BOOK  OF  GYNECOLOGY 


cap  on  the  enlarged  sac.  In  acute  obstructions,  the  kidney  is  at  first 
markedly  congested,  and  multiple  hemorrhages  may  take  place  in  the 
parenchyma  or  even  in  the  mucosa  of  the  pelvis.  As  the  enlargement 
continues,  the  secreting  portion  of  the  kidney  becomes  thinner  and 

thinner,  the  glomeruli 
are  flattened  out,  the 
canals  compressed,  and 
their  epithelial  cells  lost. 
Eventually,  this  portion 
of  the  kidney  may  be 
so  thinned  and  spread 
out  in  the  sac  wall  as 
to  be  no  longer  detect- 
able macroscopically,  al- 
though at  this  stage  a 
little  thickening  or  ir- 
regularity on  the  inner 
surface  of  the  sac  often 
indicates  the  location  of 
a  former  pyramid.  The 
secreting  function  of  the 
kidney  is  very  rarely  en- 
tirely destroyed,  even 
when  kidney  tissue  can 
no  longer  be  detected 
macroscopically.  Ayner  found  complete  destruction  of  the  kidney  tissue 
only  11  times  in  473  cases  (Traite  cle  cliirurgie  clinique  et  operatoire, 
tome  viii).  The  enlargement  may  vary  in  size  from  a  slight  dilatation 
of  the  pelvis  to  an  immense  tumour  filling  the  abdominal  cavity  and 
containing  from  15  to  20  litres  of  fiuid.  The  sac  wall  is  usually  much 
thickened,  but  may  be  quite  thin  in  places.  Attachments  by  adhesions 
to  surrounding  organs  are  common,  rendering  the  complete  removal 
of  large  sacs  at  times  very  difiicult  or  impossible. 

Partial  nephrydrosis,  a  condition  wherein  but  a  part  of  the  kidney 
is  involved  in  the  process,  may  result  when  the  anomaly  of  double 
ureter  is  present  with  imperforation  or  obstruction  of  one  (Heller), 
or  when  one  of  the  calyces  becomes  shut  off  from  the  pelvis,  as  has 
been  described  by  Fenger,  Israel,  and  others,  and  of  which  Harris  has 
seen  one  example.  The  contents  of  the  sac  are  always  normal  or 
modified  urine.  In  the  intermittent  variety,  the  urine  may  show  no 
changes  from  the  normal,  or  it  may  contain  blood  due  to  the  con- 
gestion induced  by  the  retention  as  mentioned  by  Albarran  {Annales 
des  maladies  des  organes  genito-iirin aires,  1898,  p.  470). 

In  the  closed  variety,  the  fluid  gradually  becomes  more  and  more 
changed  from  normal  urine.  The  specific  gravity  grows  less,  the 
quantity  of  chlorides,  phosphates  and  urea  is  diminished,  the  latter 
often  being  present  only  in  traces.    The  fluid  becomes  more  serous  in 


Fig.  310. — "  The  dilatation  of  the  pelvis  soon  extends  to 
the  calyces." — Hakkis  (page  763). 


THE   FEMALE   URINARY   APPARATUS  765 

character  and  contains  a  small  amount  of  albumin  with  mucous  and 
epithelial  cells  from  the  mucosa  of  the  pelvis.  Traces  of  uric  acid 
and  oxalates  may  sometimes  be  found,  even  when  all  urea  has  disap- 
peared. The  fluid  is  usually  more  or  less  clear,  but  may  be  coloured 
by  blood  from  old  hemorrhages.  Very  rarely,  the  sac  may  contain  a 
quantity  of  gas,  mostly  carbon-dioxide,  which  may  give  to  the  tumour 
a  resonant  sound  on  percussion. 

Symptomatology  and  Diagnosis. — The  symptomatology,  strictly 
speaking,  of  the  ordinary  closed  nephrydrosis  is  practically  nil.  The 
first  point  which  directs  attention  to  the  condition  is  usually  the 
accidental  discovery  of  a  tumour  in  the  lateral  region  of  the  abdo- 
men. The  tumour  develops  so  slowly  and  insidiously  that  no  symp- 
toms, save  perhaps  a  vague  sense  of  uneasiness  or  fulness  about  the 
side,  are  experienced  by  the  patient.  There  may  be  no  changes  what- 
ever in  the  quantity  or  quality  of  the  urine  passed,  or  symptoms  of 
any  kind  referable  to  the  urinary  organs.  As  the  tumour  enlarges, 
symptoms  resulting  from  pressure  upon,  and  displacement  of,  neigh- 
bouring organs  may  develop.  If  the  growth  of  the  tumour  is  observed 
for  a  time,  it  will  be  found  to  develop  from  the  upper  and  lateral  re- 
gion of  the  abdomen  in  a  direction  downward  and  inward.  If  seen 
sufficiently  early,  the  tumour  is  usually  somewhat  oval  in  outline, 
and  occasionally  in  thin  subjects  with  lax  abdominal  walls  the  de- 
marcation between  the  cystic  portion  and  the  kidney  tissue  may  be 
detected  by  palpation.  As  it  enlarges,  it  becomes  globular  in  shape 
and  the  surface  more  uniform.  The  relations  of  the  tumour  to  the  longi- 
tudinal colon,  ascending  or  descending,  respectively,  are  of  very  great 
diagnostitial  value.  This  portion  of  the  colon  will  be  found  displaced 
forward,  forward  and  inward,  or  inward.  Very  rarely,  in  a  nephry- 
drosis developing  in  a  movable  kidney,  the  longitudinal  colon  will  be 
found  to  the  outer  side  of  the  growth.  The  dull  area  of  the  tumour 
should  be  outlined  by  percussion  while  the  colon  is  empty.  This  por- 
tion of  the  intestine  should  then  be  distended  with  air  and  the  rela- 
tions to  the  tumour  observed.  The  so-called  "  renal  ballottement " 
of  Guyon  is  a  valuable  diagnostitial  sign  but  not  pathognomonic  of 
a  renal  tumour.  The  fact  that  the  tumour  contains  fluid,  may  usu- 
ally be  determined  by  the  sense  of  touch  and  by  the  presence  of  fluc- 
tuation. The  use  of  the  aspirating  needle,  as  means  of  diagnosis,  is 
seldom  advisable.  When  a  tumour  is  present  which,  owing  to  its 
location  and  relations  to  surrounding  organs,  may  be  referred  to  the 
region  of  the  kidney,  segregation  of  the  urines  (see  Methods  of  Ex- 
amination) becomes  an  important  factor  in  the  diagnosis.  If,  by  use 
of  the  urine  segregator  or  the  ureteral  catheter,  no  urine  is  found  to 
come  from  the  side  corresponding  to  the  tumour  and  the  urine  from  the 
opposite  side  represents  the  entire  output,  the  tumour  may,  with  almost 
alDsolute  certainty,  be  referred  to  the  kidney  as  its  point  of  origin. 

In  intermAtlent  nephrydrosis,  symptoms  are  frequently  present 
which  point  directly  to  the  kidney  as  the  source  of  the  trouble.     Some 


"leG  A  TEXT-BOOK  OF  GYNECOLOGY 

of  these  are  such  as  are  commonly  present  in  movable  kidney,  such 
as  an  aching  or  pain  in  the  lumbar  region  or  lateral  portion  of  the 
abdomen,  nausea,  irregular  attacks  of  frequent  urination,  etc.  Har- 
ris had  a  typical  case  in  a  woman  who,  at  irregular  intervals,  had 
attacks  of  frequent  and  painful  urination  amounting,  at  times,  almost 
to  strangury.  These  attacks  usually  lasted  two  or  three  hours.  Dur- 
ing the  intervals,  there  was  no  difficulty  whatever  in  urinating  and 
the  urine  was  normal.  In  this  case,  a  very  movable  kidney  kinked  the 
ureter  at  its  upper  portion,  producing  a  mild  degree  of  intermittent 
nephrydrosis.  The  tumour  in  these  cases  does  not  become  so  large 
as  in  the  closed  variety,  and  is  often  scarcely  perceptible.  In  other 
cases,  a  tumour  of  moderate  size  has  been  noticed  by  the  patient, 
which,  at  times,  suddenly  disappears,  its  disappearance  being  accom- 
panied by  an  unusual  flow  of  urine.  This  rise  and  fall  of  the  tumour 
is  quite  characteristic  of  an  intermittent  nephrydrosis.  Intermittent 
hematuria  has  occasionally  been  noticed  in  these  cases.  The  intro- 
duction of  the  ureteral  catheter  up  to  the  pelvis  of  the  kidney  may 
drain  away  the  fluid  and  cause  the  collapse  or  disappearance  of  the 
tumour.  The  diagnosis  of  nephrydrosis  is  never  complete  without 
taking  into  consideration  the  nature  of  the  condition  giving  rise  to 
the  obstruction.  This  should  always  be  carefully  sought.  The 
course  and  prognosis  of  these  cases  depend  entirely  upon  the  nature 
of  the  obstructing  cause.  A  simple  closed  nephrydrosis  may  exist  for 
years  with  little  inconvenience  to  the  patient,  provided  the  opposite 
kidney  is  normal.  When  both  sides  are  affected,  the  end  in  ursemia 
is  seldom  long  delayed.  When  due  to  carcinoma  of  the  bladder  or 
uterus,  death  follows  as  a  result  of  the  primary  trouble  unless  that 
admits  of  successful  surgical  removal.  Intermittent  nephrydrosis  due 
to  movable  kidney,  usually  admits  of  relief  by  permanently  restoring 
the  kidney  to  its  normal  location  and  position.  The  greatest  danger 
in  these  cases  is  that  they  may  become  infected,  thus  converting  a 
nephrydrosis  into  a  nephropyosis  with  all  the  serious  accompaniments 
of  a  septic  kidney.  A  nephrydrosis  sac  may  be  ruptured  by  trauma 
and  the  contents  scattered  throughout  the  peritoneal  cavity.  This  is 
not  necessarily  serious,  provided  the  contents  are  sterile,  but  when 
septic,  a  fatal  peritonitis  usually  results. 

Treatment. — As  nephrydrosis  is  a  secondary  condition,  dependent 
upon  some  obstruction  to  the  escape  of  the  urine,  the  treatment  should 
naturally  be  directed  to  the  cause  of  the  obstruction.  We  may  divide 
the  cases  into  two  classes,  namely:  1.  Those  in  which  the  nature  of 
the  obstruction  is  known  and  remediable;  and  2.  Those  in  which  the 
nature  of  the  obstruction  is  unknown  or  irremediable. 

Under  the  first  class  we  may  mention  the  removal  of  a  tumour 
of  the  bladder  or  a  vesical  calculus  that  is  obstructing  the  ureteral 
orifice;  removal  of  a  uterine  or  pelvic  tumoiir  pressing  on  the  ureter, 
and  dislodgment  of  a  calculus  obstructing  the  ureter  by  means  of  the 
ureteral  bougie  or  catheter;   dilatation  of  a  ureteral   stricture  with 


THE  FEMALE    URINARY  APPARATUS  767 

the  bougie.  The  use  of  the  ureteral  catheter  a  demeure  is  recoin- 
mended  by  Pawlik  and  Albarran  in  some  cases  of  open  nephrydrosis 
due,  probably,  to  valve  formation  or  compression  of  the  upper  end  of 
the  ureter.  The  catheter  has  been  retained  for  several  days  with  per- 
manent relief.  Nephropexy  may  be  done  for  movable  kidneys.  This 
operation  should  not  only  fix  the  kidney,  but  should  fix  it  in  such  a  posi- 
tion by  rotating  it,  if  necessary,  about  its  sagittal  axis,  that  the  ureter 
escapes  from  the  most  dependent  part.  In  certain  valve  formations  at 
the  uretero-pelvic  junction,  plastic  operations  after  the  method  of 
Klister  and  Fenger  may  be  tried.  Strictures  of  the  ureter  may  be 
relieved  or  ureteral  stones  removed  by  open  operation.  All  the  above 
procedures  have  for  their  aim  the  conservation  of  the  kidney  and  its 
function,  and  it  will  be  seen  how  varied  is  the  treatment  of  this  class 
of  cases. 

In  the  second  class  of  cases,  we  have  to  deal  with  the  sac  or  tumour 
itself,  as  the  cause  of  the  obstruction  is  unknown  or  can  not  be  dealt 
with  directly.  We  have  to  consider  here.  First :  Aspiration  or  punc- 
ture ;  secondly,  nephrotomy ;  thirdly,  nephrectomy. 

While  it  can  not  be  denied  that  the  use  of  the  aspirator  has  been 
followed  occasionally  by  success,  still,  the  relief  afforded  is  usually 
so  temporary,  and  the  danger  of  infection  so  great,  that  it  can  not  be 
recommended  as  a  curative  procedure.  Occasionally,  however,  aspira- 
tion may  be  employed  for  the  temporary  relief  which  it  affords  where 
the  patient  is  greatly  oppressed  by  the  enlargement,  and  her  condi- 
tion contraindicates  more  radical  measures;  or  in  the  later  stages  of 
pregnancy  when  the  emptying  of  the  uterus  is  expected  soon  to  give 
relief  to  the  pressure  on  the  ureter.  The  needle  should  always  be 
introduced  posteriorly,  so  as  not  to  traverse  the  peritoneal  cavity  or 
endanger  the  intestine.  Nephrotomy  should  always  be  performed  by 
the  lumbar  route.  It  is  advisable  to  make  the  incision  so  as  to  be 
able  to  explore  the  ureter  and  locate,  if  possible,  the  source  and  nature 
of  the  obstruction.  If  this  can  not  be  done,  the  sac  should  be  opened 
and  drained.  This  will  often  be  followed  by  permanent  recovery  but, 
in  the  majority  of  cases,  a  fistula  remains  that  continues  to  discharge 
urine.  Ordinarily,  such  a  fistula  is  of  considerable  annoyance  to  the 
patient  by  its  constant  leakage,  but,  at  times,  a  tight-fitting  tube  or 
rubber  catheter  may  be  adapted  to  the  fistula  and  opened  at  regular 
intervals  with  little  inconvenience.  Nephrotomy  should  always  be  the 
operation  of  choice  when  the  state  of  the  opposite  kidney  is  in  doubt. 
However,  when  the  opposite  kidney  is  known  to  be  healthy,  and  it  has 
been  found  impossible  to  restore  the  normal  course  of  the  urine  on  the 
diseased  side,  nephrectomy  should  be  performed.  This  may  be  done 
as  a  primary  operation,  if  the  patient's  condition  warrants  it,  or  sec- 
ondary to  a  primary  nephrotomy.  The  adhesions  usually  present, 
when  the  sac  is  large,  make  primary  nephrectomy  often  a  diificult 
operation. 


CHAPTER  XL VIII 

THE  FEMALE  URINARY  APPARATUS  (Continued) 

Renal  infections;  pathologic  changes,  symptomatology  and  diagnosis,  treatment 
— Tuberculosis  of  the  kidney ;  pathologic  changes,  symptomatology  and  diag- 
nosis, treatment  —  Renal  calculi;  pathologic  changes,  symptomatology  and 
diagnosis,  course  and  prognosis,  treatment — Tumours  of  the  kidneys;  pathol- 
ogy, symptomatology  and  diagnosis,  treatment — Operations  on  the  kidney: 
Nephropexy;  nephrotomy;  nephrectomy. 

Ik  renal  infections,  as  in  infections  in  other  tissues  of  the  body, 
the  essential  etiologic  factor  is  the  presence  of  pathogenic  microbes. 
The  kidneys,  in  the  performance  of  their  excretory  function,  are  fre- 
quently called  upon  to  eliminate  bacteria  from  the  blood  current,  and 
they  may  be  eliminated  in  the  living  state  with  the  urine  without  the 
kidneys  becoming  the  seat  of  pathologic  changes.  In  order  that  the 
kidneys  may  become  the  seat  of  the  inflanmiatory  conditions  herein 
considered,  it  is  necessary  that  the  bacteria  should  lodge  and  develop 
there.  There  are  certain  antecedent  conditions  which  favour  this  lodg- 
ment and  development  of  the  microbes.  Among  these  may  be  men- 
tioned: The  ingestion  of  certain  medicaments  which  produce  an  active 
hypera?mia  with  exfoliation  of  cells  of  the  kidney,  such  as  turpentine, 
copaiba,  cantharides,  etc.;  the  presence  of  toxines,  the  result  of  bac- 
terial invasion  elsewhere  in  the  body;  congestion  of  the  kidneys  due 
to  obstruction  to  the  return  circulation  or  to  chilling  of  the  surface  of 
the  body;  internal  trauma,  due  to  the  presence  of  a  renal  calculus  or 
other  foreign  body;  external  trauma,  subcutaneous  or  direct;  and,  per- 
haps the  most  common,  obstructions  to  or  interference  with  the  free 
escape  of  the  urine  at  some  point  along  the  excretory  channels.  AVIiile, 
at  times,  the  entire  organ  may  appear  to  be  involved,  ordinarily  the 
infection  is  sufficiently  limited  to  warrant  the  use  of  certain  descriptive 
terms.  Thus  we  may  have  a  circumscribed  parenchymatous  infection 
producing  a  kidney  abscess.  When  the  pelvis  is  more  particularly  in- 
volved, it  is  termed  pyelitis.  If  the  infection  extends  from  the  pelvis 
along  the  collecting  tubes  to  the  parenchyma,  we  have  a  nepliro pyelitis 
(pyelonephritis).  If,  in  addition  to  the  infection  of  the  pelvis,  we  find 
this  cavity  dilated,  it  is  called  nepJiropyosis.  It  should  be  understood 
that  these  terms  imply  simply  a  difference  in  degree  or  extent  of  in- 
volvement, and  that  the  kind  of  infection  and  nature  of  the  process  may 
768 


THE   FEMALE   URINARY   APPARATUS  769 

be  the  same  in  all.  We  may  likewise  find  the  different  conditions  coex- 
isting, as  for  instance,  pyelitis,  with  multiple  parenchymatous  abscess, 
etc.  The  routes  by  which  bacteria  may  reach  the  kidney  are  four, 
namely:  1.  Through  the  blood;  3.  Along  the  urinary  tract;  3.  Through 
the  lymphatics  by  contiguity;  4.  Directly  from  without  by  trauma. 
Infection  through  the  blood  is  called  hematogenous  infection;  or  some- 
times descending  infection,  owing  to  the  direction  in  which  the  infec- 
tion travels.  This  is  perhaps  the  most  common  route  in  the  female. 
The  bacteria  gain  entrance  to  the  blood  current  from  some  point  of  in- 
fection elsewhere  in  the  body  and  are  carried  to  the  kidney,  where, 
■owing  to  the  presence  of  some  of  the  antecedent  or  predisposing  condi- 
tions above  mentioned,  they  find  lodgment  and  develop.  Hematogenous 
infection  may  occur  in  connection  with  the  acute  infectious  diseases, 
isuch  as  typhoid  fever,  pneumonia,  influenza,  etc.,  or  in  septic  conditions 
following  confinement  or  miscarriages. 

Infection  from  without  inward  along  the  urinary  tract  is  called 
ascending  infection.  The  first  step  in  the  process  is  usually  a  cystitis. 
The  changes  may  remain  limited  to  the  bladder  for  an  indefinite  time 
as  the  ureteral  orifices  offer  a  considerable  barrier  to  the  passage  of 
any  of  the  contents,  bacteria  included,  of  the  bladder  into  the  ureters. 
However,  when  the  bladder  becomes  distended  or  contracts  vigorously 
to  expel  its  contents  through  an  obstructed  channel,  or  when  inflamma- 
tory changes,  ulceration,  etc.,  involve  directly  the  ureteral  orifices,  these 
may  become  incompetent  and  permit  infection  to  ascend  into  the 
ureters.  It  is  unnecessary  that  the  ureter  throughout  its  entire  length 
should  become  involved  in  the  inflammatory  process,  as  it  has  been 
■demonstrated  experimentally  that  bacteria,  as  well  as  minute  inanimate 
particles,  may  be  carried  along  the  ureter  to  the  pelvis  of  the  kidney 
by  antiperistaltic  action  of  the  ureter  or  by  propagation  along  the 
urinary  column. 

Even  in  the  presence  of  a  cystitis,  it  is  not  always  essential  that 
the  bacteria  should  reach  the  kidney  through  the  ureter,  as  a  hemato- 
genous infection  may  take  place  from  such  a  local  infection  as  well 
as  any  other.  Propagation  by  contiguity  may  take  place  from  the 
bowel  in  colitis,  severe  constipation,  subcutaneous  contusion  of  the 
bowel,  etc.,  as,  when  the  integrity  of  the  bowel  wall  has  been  compro- 
mised in  any  manner,  bacteria  may  escape  through  it. 

Infection  may  also  occur  as  the  result  of  a  perirenal  abscess  due 
to  an  appendicitis,  an  infection  from  the  gall  bladder,  or  from  a  hepatic 
or  subphrenic  abscess.  Direct  infection  is  always  due  to  a  penetrating 
wound. 

A  variety  of  bacteria  have  been  found  as  the  infecting  agent  in 
these  cases.  In  79  cases  reported  by  Albarran,  Schmidt  and  Aschkoff, 
Wumschein  and  Savor,  the  colon  bacillus  was  found  pure  48  times,  6 
times  associated  with  Bacillus  proteus,  and  5  times  with  the  staphylo- 
coccus or  streptococcus;  with  the  Staphylococcus  pyogenes  aureus  or  the 
streptococcus,  11  times;  the  Bacillus  typhosus,  twice;  and  the  Diplococcus 
r,n 


770  A  TEXT-BOOK  OF  GYNECOLOaY 

pneumonice,  once.  Although  the  gonococcus  is  unquestionably  a  com- 
mon cause  of  the  urethritis  and  cystitis  which  so  often  precede  the 
renal  infection,  it  does  not  appear  to  have  been  frequently  found  alone 
in  the  kidney.  From  the  foregoing,  it  will  be  seen  that  the  colon  bacil- 
lus is  the  organism  most  commonly  found  in  these  cases,  and  this  fact 
indicates  the  frequency  with  which  the  infection  proceeds  from  the 
intestine.  In  the  etiology  of  nephropyosis,  all  those  conditions  which 
lead  to  dilatation  of  the  pelvis,  mentioned  under  nephrydrosis,  are 
equally  active,  the  only  difference  being  the  addition  of  an  infection. 

The  pathologic  changes  vary  somewhat  according  to  the  manner  of 
infection.  In  hematogenous  infections,  there  may  be  one  or  more  ab- 
scesses of  varying  size  due  to  the  lodgment  of  septic  emboli,  and  pre- 
senting the  same  characteristics  as  pysemic  abscesses  in  other  organs 
of  the  body.  Again,  there  may  be  a  diffuse  involvement  of  the  kidney 
with  masses  of  microbes  found  in  the  glomeruli  and  about  the  secret- 
ing tubes,  which  lead  to  swelling,  coagulation  necrosis,  and  exfoliation 
of  the  cells  with  peripheral  leucocytic  infiltration.  When  the  infection 
extends  from  the  pelvis,  the  microbes  are  found  ascending  the  collect- 
ing tubes,  often  reaching  as  far  as  the  secreting  portion,  producing 
the  same  destructive  effect  on  the  epithelial  cells,  and  leading  to  in- 
creased interstitial  connective-tissue  formation. 

In  pyelitis,  the  mucosa  of  the  pelvis  is  thickened  and  reddish  or 
grayish  in  colour.  Circumscribed  denudations  or  superficial  ulcerations 
may,  at  times,  be  seen  particularly  about  the  tips  of  the  pyramids. 
The  mucous  membrane  is  often  covered  by  a  thin  layer  composed  of 
pus  cells,  exfoliated  epithelia,  microbes,  mucus,  etc.,  which  gives  to 
the  membrane  a  vsmooth  velvety  feel  to  the  touch. 

In  nephropyosis,  in  addition  to  the  changes  in  the  mucosa  already 
noted,  the  pelvis  is  found  more  or  less  dilated.  The  dilatation  may  be 
slight,  or  so  great  that  the  kidney  tissue  is  compressed  and  flattened  out 
so  that  the  entire  organ  forms  but  a  large  pus  sac.  Usually,  the  dilata- 
tion is  but  moderate,  and  the  calyces  form  pouches  or  pus  sacs  com- 
municating with  the  pelvis,  the  pyramids  being  so  compressed  as  to 
present  the  appearance  of  trabecular  extending  through  the  cavity. 
Concretions  are  often  found  in  the  calyces  or  pelvis.  A  calyx  may  be- 
come shut  off  from  the  pelvis,  thus  forming  a  circumscribed  abscess, 
and  independent  abscesses  in  the  kidney  tissue  which  do  not  communi- 
cate with  the  pelvis  are  common. 

When  the  infection  has  been  an  ascending  one,  the  ureter  often 
shows  marked  changes  due  to  chronic  inflammation.  Its  walls  are  much 
thickened,  it  becomes  dilated,  elongated,  and  tortuous,  and  reduplica- 
tions of  the  mucosa  lead  to  the  formation  of  valvelike  strictures.  Peri- 
nephritis with  abscess  formation  is  quite  common,  and,  in  nephropyosis, 
adhesions  to  surrounding  parts  the  rule. 

Symptomatology  and  Diagnosis. — The  symptoms  may  be  arranged 
under  three  heads:  1.  General;  3.  Local;  3.  Urinary  Changes.  The 
onset  may  be  acute  or  slow  and  insidious.     When  renal  abscesses 


THE   FEMALE  URINARY   APPARATUS  771 

occur  in  the  course  of  a  pyaemia,  the  condition  is  usually  unrecognised 
owing  to  the  severity  of  the  general  disorder,  and  the  abscesses  are 
found  only  at  the  autopsy.  In  an  acute  case  following  general  ex- 
posure, or  after  confinement,  or  from  a  sudden  extension  of  an  infection 
from  the  bladder,  the  temperature  will  be  found  elevated,  101°  to  103° 
F.,  with  the  usual  symptoms  accompanying  fever.  Locally,  there  will 
be  pain  in  the  lumbar  region  with  distinct  tenderness  as  the  kidney 
is  grasped  between  the  two  hands.  In  many  cases  of  ascending  infec- 
tion, the  kidney  becomes  involved  so  insidiously  that  it  is  frequently 
impossible  to  tell  just  when  this  organ  began  to  be  affected.  There 
will  be  an  elevation  of  a  degree  or  two  in  the  temperature,  particu- 
larly toward  evening,  with  gradual  loss  of  weight  and  deterioration  of 
the  general  health.  The  kidney,  if  palpable,  will  usually  be  felt  to  be 
slightly  enlarged  and  tender  on  pressure.  There  may  be  pain  in  the 
region  of  the  kidney,  at  times  simulating  mild  attacks  of  renal  colic. 
Frequent  urination  is  the  rule,  and  it  may  be  present  even  when  there 
is  no  involvement  of  the  bladder.  Changes  in  the  character  of  the 
urine  are  always  present.  It  will  be  found  to  contain  a  variable  amount 
of  pus  and  albumin,  numerous  bacteria,  and  epithelial  cells  from  the 
pelvis  as  well  as  from  the  tubules,  should  these  be  involved.  Cylin- 
droids  and  casts  will  be  present  if  the  kidney  substance  is  affected,  but 
may  be  absent  when  the  infection  is  limited  to  the  pelvis.  The  reaction 
of  the  urine  will  depend  upon  the  kind  of  microbe  present.  The  urine 
may  remain  acid  throughout  when  the  infection  is  due  to  the  colon 
bacillus  as  well  as  to  some  varieties  of  streptococcus,  but  the  usual 
Staphylococcus  pyogenes  aureus  and  the  proteus  decompose  urea,  thus 
rendering  the  urine  alkaline.  It  then  often  contains  the  common  triple 
phosphate  crystals.  There  is  nothing  characteristic  about  the  pus  or 
the  epithelial  cells  to  indicate  their  origin  from  the  pelvis  of  the  kidney. 
When  the  origin  of  these  pathologic  products  is  in  doubt,  it  will  be 
necessary  to  collect  the  urines  directly  from  the  kidneys  by  catheteriza- 
tion of  the  ureters,  or  by  the  use  of  the  urine  segregator. 

In  nephropyosis  the  appearance  of  pus  in  the  urine  may  be  inter- 
mittent. If  the  affection  is  unilateral,  the  opposite  kidney  in  the  in- 
terval may  furnish  perfectly  normal  urine.  The  kidney  is  always  more 
or  less  enlarged  in  nephropyosis,  and,  at  times,  the  tumour  reaches  con- 
siderable dimensions.  The  diagnostic  points  which  indicate  the  renal 
origin  of  the  tumour  have  already  been  referred  to  under  Methods  of 
Examination. 

The  course  of  these  infections  is  variable.  Many  cases  following 
confinement  recover  entirely.  In  other  cases,  the  pus  may  disappear 
but  the  bacteria  remain,  leaving  a  condition  of  simple  bacteriuria.  If 
the  affection  is  unilateral,  it  may  persist  in  a  mild  way  for  several  years 
without  materially  injuring  the  general  health,  but  the  opposite  kidney 
is  always  liable  to  become  affected,  which  adds  materially  to  the  serious- 
ness of  the  condition.  When  abscesses  develop  in  the  kidney  substance 
or  in  the  perirenal  tissues,  death  may  take  place  from  sepsis,  or  from 


^772  A  TEXT-BOOK  OF  GYNECOLOGY 

ur£eiiiia  when  a  considerable  amount  of  the  kidney  tissue  is  destroyed. 
The  prognosis  is  also  somewhat  influenced  by  the  kind  of  infection 
present,  a  colon-bacillus  infection,  for  instance,  being  more  favourable 
than  one  due  to  the  streptococcus. 

In  the  treatment,  due  consideration  should  be  given  to  antecedent 
conditions,  as  cystitis,  pelvic  infections,  primary  perinephric  abscesses, 
intestinal  complications,  etc.  For  the  renal  affection  itself,  the  admin- 
istration of  large  quantities  of  distilled  water  to  induce  free  flushing 
of  the  kidneys  is  of  advantage.  At  the  same  time  may  be  given  some 
of  the  antiseptic  agents  which  are  eliminated  with  the  urine,  and  of 
these  the  formalin  compounds,  such  as  urotropin  and  cystogen,  appear 
to  be  the  most  useful.  Salol,  boric  acid,  and  benzoic  acid,  are  also,  at 
times,  of  value.  Direct  treatment  of  the  pelvis  in  pyelitis  by  irrigation 
through  the  ureteral  catheter,  as  practised  by  Kelly,  Casper,  and  others, 
has  given  good  results  in  some  cases.  The  solutions  used  are  boric 
acid;  dilute  nitrate  of  silver  1  to  1,000;  and  bichloride  of  mercury 
1  to  150,000  gradually  increased  to  1  to  16,000  (Kelly).  They  should 
be  used  warm  and  with  great  care.  This  treatment  does  not  appear  ad- 
visable in  cases  with  fever  (Casper),  as  chills  with  high  temperature 
may  follow.  Should  these  means  fail  to  give  relief,  nephrotomy  with 
drainage  through  the  lumbar  region  may  be  tried.  At  the  same  time, 
all  complicating  conditions  should  be  relieved,  if  possible,  such  as 
removal  of  calculi,  correction  of  strictures  or  obstructions  of  the 
ureter,  fixation  of  movable  kidney,  etc.  As  a  last  resort,  and  only  when 
it  is  positively  known  that  the  opposite  kidney  is  normal,  may  nephrec- 
tomy be  performed. 

Tuberculosis  of  the  Kidney. — In  acute  miliary  tuberculosis  the  kid- 
neys may  be  involved  in  connection  with  the  other  organs  of  the  body, 
but  as  such  cases  have  no  special  interest  to  the  surgeon,  they  will  not 
be  further  considered  here. 

Surgical  tuberculosis  of  the  kidney  may  exist  as  a  primary  affection, 
or  it  may  be  secondary  to  tuberculosis  of  other  portions  of  the  urinary 
tract  or  of  contiguous  structures.  In  the  primary  variety,  it  is  well 
understood  that  an  infection  atrium  must  have  existed  at  some  pre- 
vious time  through  which  the  tubercle  bacillus  gained  entrance  to  the 
body,  and,  in  many  of  these  cases,  a  latent  tuberculous  focus  is  found 
in  the  shape  of  an  old  tuberculous  bronchial  or  mesenteric  lymph  gland. 
The  bacilli  are  carried  to  the  kidneys  by  the  blood  and  the  process  is 
therefore  a  pure  hematogenous  infection. 

Women  are  more  commonly  affected  than  men  in  the  proportion  of 
29  women  to  14  men  (Tuffier);  148  women  to  55  men  (Albarran);  and 
73  women  to  59  men  (Bangs);  a  total  of  378  cases,  with  350  women, 
or  66  per  cent.  Almost  any  age  may  be  affected,  but  75  per  cent  of 
the  cases  occur  between  the  ages  of  twenty  and  forty  years.  The  kidney 
is  primarily  affected  in  a  majority  of  the  cases,  and  usually,  at  first, 
but  one  organ  is  involved.  Later  the  opposite  organ  may  become 
affected. 


THE   FEMALE   URINARY  APPARATUS 


Y73 


Fig.  311. 


"  Tuberculous  abscesses  are  produced." 
— Harkis. 


Tuberculosis  of  the  kidney  secondary  to  involvement  of  the  lower 
urinary  tract,  is  not  so  common  in  women  as  in  men,  in  whom  we  may 
have  a  primary  affection  of  the 
prostate,  seminal  vesicles,  epi- 
didymis, etc.  A  tuberculous 
abscess  originating  in  the  ver- 
tebrae (Pott's  disease)  or  from 
the  bowel,  may  extend  to  and 
involve  the  kidney  secondarily. 
Pathologic  Changes.  —  The 
most  common  form  observed  is 
the  large  tuberculous  nodule. 
Such  a  nodule  is  made  up  of  a 
conglomerate  mass  of  histo- 
logic tubercles,  forming  a 
grayish  or  yellowish  mass  vary- 
ing from  0.5  centimetre  to  2 
or  3  centimetres  in  diameter. 
Often,  there  is  but  a  single 
nodule,  when  it  commonly  oc- 
cupies one  or  the  other  pole, 
but  they  may  be  multiple  and 
disseminated  throughout  the 
kidney.    The  nodules  undergo 

the  usual  changes  so  characteristic  of  tuberculous  tissue,  namely  casea- 
tion, and  softening  or  liquefaction.  In  this  manner,  tuberculous  ab- 
scesses are  produced  which 
may  rupture  into  the  pelvis 
or  on  the  surface  of  the  kid- 
ney into  the  perinephric  tis- 
sue (Fig.  311).  The  walls  of 
such  abscesses  become  lined 
with  the  usual  tuberculous 
granulations  which  show  oc- 
casional giant  cells  (Fig. 
312),  and  the  surrounding 
kidney  tissue  shows  the  ordi- 
nary inflammatory  changes. 
In  tuberculous  pyelitis,  small 
tubercles  may  be  found  dis- 
seminated more  or  less  thick- 
ly in  the  mucosa.  As  these 
soften  and  break  down,  small 
ulcers  are  formed.  A  sin- 
gle small  tubei'culous  ulcer 
on  one  of  the  pyramids  may  give  rise  to  pronounced  hematuria, 
which  may  persist  for  a  long  time  witlioiit  any  other  symptoms  being 


Fig. 


312. — "Tlie  wallH  of  such  abscesses  . 
occasional  giant  cells." — Harris. 


show 


774  A   TEXT-BOOK  OF   GYNECOLOGY 

present.  The  ureter  may  become  involved  with  the  production  of 
caseous  nodules  or  masses,  which  may  interfere  with  the  escape  of  the 
urine  and  thus  lead  to  the  development  of  a  tuberculous  nephropyosis. 
A  mixed  infection  in  these  cases  is  very  common,  the  ordinary  pyogenic 
organisms  being  the  ones  most  frequently  found.  In  almost  all  cases 
of  tuberculosis  of  the  kidney  that  have  existed  for  any  length  of  time, 
marked  changes  occur  in  the  perirenal  tissues.  Some  of  the  fat  be- 
comes absorbed,  while  the  connective  tissue  is  greatly  increased  in 
amount.  The  entire  fatty  capsule  thus  becomes  converted  into  a 
dense,  hard  mass,  surrounding  the  kidney,  and  so  intimately  attached 
to  the  adjoining  structures,  particularly  the  colon  and  great  vessels, 
that  it  is  often  impossible  to  detach  it  from  them  without  great  danger 
of  injury.  This  perinephritis  fibrosa  may  form  a  tumour  of  consider- 
able size  easily  palpable  through  the  abdominal  wall.  The  tuberculous 
kidney  occupies  the  interior  of  this  dense  capsule,  and  while  it  is,  at 
times,  difficult  or  impossible  to  remove  the  capsule  itself,  the  kidney 
is  fortunately  usually  easily  enucleable  from  its  centre.  Provided  all 
the  tuberculous  tissue  is  removed  with  the  kidney,  this  dense  peri- 
nephric mass  may  entirely  disapj)ear  by  absorption.  When  numerous 
abscesses  develop,  rupturing  into  the  pelvis  or  into  each  other,  the  en- 
tire kidney  substance  may  practically  be  destroyed,  and  nothing  remain 
but  abscess  cavities  whose  walls  are  lined  with  tuberculous  granula- 
tions. The  lymph  glands  about  the  hilum  of  the  kidney  may  become 
tuberculous,  forming  distinct  separate  nodules. 

Symptomatology  and  Diagnosis. — The  onset  of  tuberculosis  of  the 
kidney  is  often  obscure.  One  of  the  most  frequent  symptoms  in  the 
early  stage  is  hematuria.  This  may  be  in  quantity  scarcely  sufficient 
to  give  colour  to  the  urine,  or  quite  profuse,  and  it  may  persist  for  some 
time.  It  usually  apjjears  spontaneously,  being  discovered  by  the  pa- 
tient by  accident,  and  is  not  materially  influenced  by  exercise  or  repose. 
If  the  hemorrhage  is  profuse  enough,  clots  may  form,  the  passage  of 
which  along  the  ureter  may  give  rise  to  severe  pain.  Such  clots  formed 
in  the  ureter  have  a  characteristic  wormlike  appearance  when  passed. 
In  the  later  stages,  hematuria  is  less  common.  Frequent  urination, 
accompanied  with  more  or  less  pain,  is  a  very  common  symptom,  and 
may  be  present  when  there  is  no  trouble  whatever  with  the  bladder. 
It  is  then  a  reflex  or  irradiation  symptom,  and  is  of  great  diagnostic 
value  in  the  early  stages.  More  or  less  jDain  or  ache  in  the  lumbar 
region  is  the  rule,  and  frequently  sharp  jDains  of  short  duration  may 
be  felt,  which  resemble  mild  renal  colic,  but  which  may  occur  when  no 
solid  substance  passes  the  ureter;  they  are  then,  probably,  in  the  nature 
of  neuralgia  of  the  ureter.  The  kidney  is  usually  somewhat  enlarged 
and  tender  on  pressure.  Changes  in  the  urine  are  always  sooner  or 
later  present,  but  during  the  early  stage  they  may  not  be  very  marked. 
Blood,  as  already  mentioned,  may  be  present.  It  may  be  so  slight  in 
amount  as  to  require  the  microscope  for  its  detection,  or  so  profuse 
that  the  urine  may  appear  like  blood.    More  or  less  pus  is  always  pres- 


THE   FEMALE    URINARY   APPARATUS  775 

ent,  together  with  e^Dithelial  cells  from  the  pelvis  and  tubules.  Albu- 
min is  found,  and  in  excess  of  what  it  is  usual  to  ascribe  to  the  pus 
present.  While  casts  are  not  essential  to  the  tuberculous  process,  a 
few  can  usually  be  found  owing  to  circumscribed  patches  of  ne- 
phritis. 

The  above-mentioned  urinary  changes  are  not  characteristic  of 
tuberculosis  but  are  common  to  j^yelitis  or  nephropyelitis  whatever  the 
nature  of  the  infecting  agent  may  be.  The  detection  of  the  tubercle 
bacillus  in  the  sediment,  therefore,  is  necessary  to  an  absolute  diag- 
nosis. 

In  most  cases  the  bacillus  can  be  found,  if  sufficient  urine  is  sub- 
mitted to  the  centrifuge  and  the  sediment  properly  stained.  It  may 
be  necessary  to  examine  a  number  of  specimens  before  finding  any, 
and  sometimes  one  fails  even  after  repeated  examinations.  In  these 
cases,  inoculation  experiments  may  demonstrate  the  tuberculous  nature 
of  the  affection.  It  is  quite  probable  that  a  jDurulent  urine,  acid  in 
reaction,  in  which  none  of  the  ordinary  bacteria  are  present,  comes 
from  a  tuberculous  kidney,  even  when  no  tubercle  bacilli  can  be  found. 
In  later  stages  mixed  infection  may  occur  and  the  urine  may  be  found 
to  contain  the  ordinary  pyogenic  microbes  as  well  as  the  tubercle  bacil- 
lus. During  the  early  stages,  there  is  usually  no  fever,  but,  later, 
a  rise  of  from  one  to  two  degrees  is  noted  toward  evening. 

The  prognosis  of  tuberculosis  of  the  kidney  in  general  is  not  good, 
and  when  both  kidneys  are  involved  it  is  certainly  bad,  although  re- 
covery is  possible.  In  primary  unilateral  tuberculosis,  where  the  kid- 
ney involved  is  removed,  the  prognosis  is  very  good.  Harris  has 
patients  living  five  and  six  years  after  nephrectomy  for  unilateral  tuber- 
culosis, who  are  in  perfect  health.  When  the  bladder  becomes  affected 
and  mixed  infections  are  present,  the  prognosis  is  again  bad. 

Treatment. — While  it  can  not  be  denied  that  tuberculosis  of  the 
kidney  may  be  recovered  from  spontaneously  or  under  treatment,  still 
the  probabilities  of  such  a  favourable  termination  are  too  remote  to 
be  depended  upon.  In  primary  unilateral  tuberculosis,  the  rational 
treatment  is  nephrectomy.  Even  the  presence  of  beginning  trouble  in 
the  apex  of  the  lungs  or  of  albuminuria  from  the  opposite  kidney  is  not, 
in  itself,  a  contraindication  to  nephrectomy  in  these  cases,  as,  after 
removal  of  the  principal  and  primary  focus,  these  secondary  conditions 
may  clear  up  and  disappear.  Unless  the  bladder  is  actually  invaded 
by  the  tuberculous  process,  the  vesical  symptoms,  so  common  when  the 
kidney  is  involved,  may  also  entirely  disappear  after  removal  of  the 
kidney.  It  is  doubtful  if  resection  of  the  kidney,  as  has  been  done,  is 
advisable  in  tuberculosis,  because  even  in  the  nodular  variety,  it  is  im- 
possible to  tell  whether  there  may  not  be  small  impalpable  nodules  in 
the  apparently  healthy  portion,  or  to  what  extent  the  pelvis  may  be 
involved,  thus  permitting  reinfection. 

Wbon  the  kidney  infection  is  secondary  to  advanced  tuberculosis 
in  other  portions  of  the  body  or  when  both  kidneys  are  extensively 


776  A   TEXT-BOOK   OF  GYNECOLOGY 

involved,  nephrectomy  should  not  be  done,  but,  even  here,  nephrotomy 
for  the  purpose  of  draining  large  purulent  accumulations,  may  be 
advisable.  In  all  cases,  proper  hygienic,  climatic,  and  medicinal  meas- 
ures, should  be  instituted. 

Renal  Calculi. — Kidney  stones  are  due  to  the  precipitation  and 
agglutination  of  salts  normally  or  abnormally  present  in  the  urine. 
These  two  conditions  are  absolutely  necessary.  The  substance  must 
not  only  be  precipitated,  but  the  crystals  or  particles  forming  it  must 
cohere  or  become  agglutinated  to  form  a  mass.  Various  factors  are 
instrumental  in  causing  precipitates  in  the  urine,  such  as  changes  in 
the  reaction  and  temperature,  variations  in  the  relative  or  absolute  pro- 
portion of  the  salts  present,  and  the  presence  of  abnormal  constituents.. 
These  conditions  are  brought  about  by  the  character  and  amount  of 
food  and  drink  taken,  the  nature  of  the  digestive  changes,  individual 
peculiarities  of  internal  metabolism,  etc. 

The  fact,  however,  that  uric  acid,  oxalates,  urates,  phosphates,  etc.,. 
may  be  passed  suspended  in  the  urine  for  almost  indefinite  periods  of 
time  without  calculi  appearing,  shows  conclusively  that  other  condi- 
tions are  essential  to  stone  formation.  Among  these  conditions,  may 
be  mentioned  a  nucleus  or  centre  about  which  the  salts  may  become 
deposited.  The  importance  of  a  nucleus  has  been  mentioned  by  a  num- 
ber of  writers.  Ebstein  considers  that  the  exfoliated  epithelial  cells 
from  the  tubules  or  pelvis  often  form  nuclei  of  stones,  but  in  acute 
nephritis  of  scarlatina,  where  exfoliation  is  so  marked,  stones  do  not 
occur.  Blood  clots  are  likewise  often  mentioned  in  this  connection, 
but  a  blood  clot  has  remained  in  the  kidney  a  year  and  a  half  (Maas) 
without  giving  rise  to  the  slightest  deposit  about  it.  We  must,  there- 
fore, search  further  for  a  common  cause.  This  has  been  suggested  b}^ 
Gallippe  to  be  the  presence  of  microbes.  Harris,  in  a  recent  article  on 
Renal  Calculi  {Journal  of  the  American  Medical  Association,  March  17, 
1900),  has  shown  by  experimental  and  clinical  evidence  the  causal  rela- 
tion between  the  presence  of  microbes  in  the  urine  and  stone  forma- 
tion. It  has  long  been  kno^^Ti  that  stones  frequently  develop  second- 
arily to  suppurative  infections  of  the  kidneys,  and,  for  this  reason,, 
kidney  stones  have  been  classed  as  primary,  or  those  developing  in 
kidneys  not  the  seat  of  surgical  infections,  or,  in  other  words,  of  non- 
microbic  origin;  and  secondary,  or  those  developing  in  kidneys  the 
seat  of  surgical  infections,  and  therefore  of  microbic  origin.  Harris 
has  shown,  however,  that  so-called  primary  stones  are  likewise  of  mi- 
crobic origin. 

The  facts  upon  which  this  statement  rests,  which  are  elaborated 
in  the  article  mentioned,  may  be  briefly  stated  as  follows:  Precipita- 
tion alone  does  not  cause  stone.  Foreign  bodies,  such  as  exfoliated 
epithelial  cells,  blood  clots,  or  those  introduced  experimentally  from' 
without,  do  not  cause  stone  so  long  as  they  remain  free  from  microbes. 
The  kidneys  frequently  eliminate  microbes  with  the  urine  without 
themselves  becoming  the  seat  of  microbic  invasion.     These  microbes; 


THE  FEMALE   URINARY   APPARATUS  777 

may  develop  in  the  urine  in  the  pelvis  and  cause  the  precipitation  of 
certain  salts.  The  character  of  the  precipitate  dejiends,  not  entirely 
upon  the  composition  of  the  urine,  but  also  uj^on  the  kind  of  microbe 
present.  The  microbes,  in  developing,  form  zoogloea  masses,  in  and 
about  which  the  precipitate  takes  place.  The  agglutination  of  the 
particles  by  the  zoogloea  mass  forms  the  nucleus  or  starting  point  of 
the  stone.  Such  zoogloea  masses  have  been  found  clinically  in  the  urine. 
The  microbe  most  frequently  found  in  the  urine  is  the  colon  bacillus. 
It  grows  in  acid  urine,  and  under  proper  conditions  causes  the  pre- 
cipitation of  uric  acid  or  acid  urates.  The  most  common  primary  stone 
is  composed  of  uric  acid  and  the  urates.  Microbes  have  been  found  in 
the  centre  of  so-called  primary  stones.  From  the  clinical  side,  we  find 
stones  frequently  preceded  by  a  history  of  acute  or  chronic  intestinal 
disorders;  of  suppurative  lesions  of  the  skin;  of  acute  infectious  dis- 
eases, as  influenza,  pneumonia,  typhoid  fever,  etc.;  and  women  very 
commonly  date  the  beginning  of  their  trouble  from  a  confinement  or 
imperfect  puerperium.  These  conditions  are  all  such  as  readily  account 
for  the  presence  of  microbes  in  the  urine.  These  facts  briefly  men- 
tioned lead  Harris  to  state  that  practically  all  kidney  stones  are  of 
microbic  origin.  The  only  value,  therefore,  of  the  classification  of 
stones  into  primary  and  secondary  is,  that  the  former  may  occur  in  a 
kidney  which  is  not  itself  the  seat  of  microbic  invasion,  while  the 
latter  are  always  secondary  to  an  infective  process  in  the  kidney.  Of 
the  primary  stones,  from  75  to  80  per  cent  are  composed  of  uric  acid 
and  the  urates.  Next  in  frequency,  come  oxalate  of  lime  and,  rarely, 
dibasic  phosphate  of  lime.  A'^ery  rarely,  stones  have  been  found  com- 
posed of  cystin,  xanthin,  indigo,  cholesterin  and  fibrin.  The  etiology 
of  these  is  not  fully  understood.  Those  of  the  uric-acid  group  are  yel- 
lowish or  brown  in  colour,  rather  smooth,  or  even  polished  if  multiple, 
and  often  somewhat  flattened  and  oval  in  shape.  Oxalate  stones  are 
hard,  dark  in  colour,  more  or  less  spherical  in  shape,  and  rough  or 
nodular  on  the  surface. 

Secondary  stones  are  formed  of  the  decomposition  products,  such  as 
ammonio-magnesium  phosphate,  phosphate  and  carbonate  of  lime,  and 
urate  of  ammonium.  They  are  usually  whitish  in  colour,  irregular  in 
outline,  present  a  rough  granular  surface,  and  are  fragile.  Stones  are 
frequently  not  of  uniform  composition,  but  made  up  of  difi'erent  layers. 
It  is  very  common  to  find  primary  stones  incrusted  with  phosphates 
after  the  kidney  has  become  septic.  Stones  may  be  single  or  multiple. 
Harris  has  removed  as  many  as  52  well-formed  bright,  polished,  uric- 
acid  stones,  from  a  kidney  with  a  history  of  trouble  extending  over 
twenty-five  years.  In  size,  they  may  vary  from  small  granules  to  a 
large  stone  filling  the  entire  pelvis,  with  irregular  bi-anches  extending 
into  the  calyces  and  upper  end  of  the  ureter,  and  weighing  several 
ounces.  While  they  usually  occupy  the  pelvis  or  calyces,  stones  may  be 
found  embedded  in  the  parenchyma  of  the  organ.  An  important  point 
is  the  frequency  with  which  stones  are  found  simultaneously  in  both 


778  A  TEXT-BOOK  OF   GYNECOLOGY 

kidneys.  This  lias  been  variously  estimated,  but  about  1  ease  in  5 
or  6  is  23erhaps  near  the  average.  Those  of  any  age  may  be  affected, 
but  from  thirty  to  sixty  years  is  the  most  favourable  time. 

Pathologic  changes  always  develop  sooner  or  later  in  kidneys  the 
seat  of  stone.  These  take  the  form  of  chronic  nephritis,  the  interstitial 
changes  usually  being  most  marked.  The  changes  may  be  so  extensive 
that  the  organ  becomes  greatly  atrophied  and  its  excreting  function 
much  reduced.  The  stone  may  be  so  located  as  to  obstruct  the  free 
escape  of  urine  from  the  pelvis,  thus  giving  rise  to  a  nephrydrosis. 
Even  in  so-called  primary  stones,  the  constant  trauma  which  they  inflict 
upon  the  interior  of  the  kidney  renders  the  organ  particularly  liable 
to  infection,  and,  in  fact,  this  almost  always,  sooner  or  later,  takes 
place.  There  are  now  added  all  the  additional  dangers  of  a  septic 
kidney:  Pyelitis,  nephropyelitis,  nejDhropyosis,  parenchymatous  and 
perinephric  abscesses,  etc. 

Symptomatology  and  Diagnosis. — The  symptoms  may  be  discussed 
under  three  heads:  1.  Pain,  including  tenderness;  3.  Changes  in  the 
character  of  the  urine;  3.  Abnormal  urination. 

The  pain  is  of  two  kinds:  Acute  intermittent  paroxysms,  which  are 
so  familiar  under  the  name  of  renal  colic,  and  the  dull  more  or  less  con- 
stant ache  in  the  lumbar  or  lateral  abdominal  region.  The  passage  of  a 
small  stone  along  the  ureter  gives  rise  to  an  attack  of  typical  renal  colic, 
but  similar  attacks,  perhaps  somewhat  less  severe,  may  occur  without  the 
passage  of  a  stone.  The  more  or  less  constant  pain  is  usually  increased 
by  exercise  (driving  or  riding)  that  jolts  the  body,  and  may  radiate  in 
almost  any  direction,  downward  to  the  bladder,  upward  to  the  costal 
region,  across  the  abdomen,  or  into  the  thigh.  Persistent  pain  in  the 
latero-lumbar  region  or  radiating  in  any  direction  from  this  region, 
which  is  otherwise  unaccountable  for,  should  always  excite  a  suspicion 
of  renal  calculus.  Tenderness  over  the  region  of  the  kidney  or  along  the 
ureter  is  often  present,  and  may  be  of  some  importance  in  determining 
the  side  affected.  One  of  the  most  peculiar  features  of  the  pain  is  the 
fact  that  rarely  it  may  be  located  on  the  side  of  the  body  opposite  to  the 
kidney  affected  (Tuckerman,  Battle). 

Under  the  head  of  urinary  changes  may  be  mentioned  the  presence 
of  blood,  pus,  epithelial  cells,  crystals,  and  bacteria,  in  the  urine.  The 
character  of  the  hematuria  is  of  some  diagnostic  importance.  A  sudden 
macroscopic  hematuria  is  probably  not  due  to  a  stone  in  the  kidney. 
We  more  commonly  meet  with  microscopic  hematuria.  The  rather 
constant  presence  of  a  few  red  blood  cells  in  the  urine,  discovered  only 
with  the  microscope,  which  quantity  of  blood  may  be  increased  by 
exercise  such  as  dancing,  riding,  driving,  etc.,  to  visible  proportions, 
is  quite  characteristic  of  kidney  stone.  The  hemorrhage  is  due  to  the 
local  action  of  the  stone  on  the  walls  of  the  cavity  which  contain  it, 
and  is  proportionate  to  the  roughness  of  the  surface  of  the  stone  and 
to  its  degree  of  mobility.  A  small  movable  stone  may  excite  consid- 
erable bleeding  and  a  very  large  fixed  one  almost  none.     Pus  in  the 


THE   FEMALE    URINARY   APPARATUS  779 

urine  is  simply  indicative  of  an  infection  of  some  portion  of  the  urinary 
tract.  Its  exact  point  of  origin  must  be  known  to  give  it  a  more  specific 
significance.  With  the  exception  of  the  secreting  cells  of  the  kidney, 
the  epithelial  cells  lining  the  urinary  tract  do  not  present  local  char- 
acteristic differences.  The  rather  frequent  or  persistent  presence  of 
particular  crystals  in  the  urine  in  considerable  amount,  may  give  a  hint 
as  to  the  character  of  the  stone  present.  Bacteria  in  the  ui-ine  are  of 
diagnostic  importance,  aside  from  determining  the  kind  of  infection, 
only  when  taken  in  consideration  with  other  symptoms.  It  will  be 
seen,  therefore,  that  the  urinary  changes  in  themselves  are  not  diag- 
nostic of  renal  calculus,  for  the  simple  reason  that  it  is  impossible  to 
tell  from  their  mere  presence  alone  from  what  part  of  the  urinary  tract 
the  pathologic  products  have  had  their  origin.  In  order  to  be  certain 
of  their  origin,  it  is  often  necessary  to  collect  the  urines  directly  from 
the  kidneys,  either  by  catheterizing  the  ureters,  or  by  the  use  of  the 
urine  segregator.  While  a  stone  that  gives  rise  to  pain  almost  always 
gives  rise  to  pathologic  products  in  the  urine,  it  should  not  be  forgotten 
that  a  stone  fixed  in  the  parenchyma  of  the  kidney  may  give  rise  to 
pain  for  years  without  the  appearance  of  any  pathologic  elements 
in  the  urine  (Miiller). 

Abnormal  urination,  in  the  shape  of  increased  frequency  or  pain, 
is  sometimes  present,  but  is  not  in  itself  indicative  of  stone.  At  times 
a  stone  lodged  in  the  ureter,  and  rarely  one  in  the  pelvis,  may  be  de- 
tected by  the  introduction  of  a  ureteral  bougie.  Keely  has  recom- 
mended that  the  tip  of  the  bougie  be  covered  with  wax  in  order  that  it 
may  receive  impressions  if  brought  in  contact  with  a  rough  stone.  The 
use  of  the  X-ray  is  often  of  great  value  in  the  diagnosis  of  kidney 
stones.  A  well-defined  positive  shadow  is,  under  proper  conditions, 
quite  certain  evidence,  but  negative  evidence  can  not  at  present  be 
considered  conclusive. 

Course  and  Prognosis. — A  stone  may  exist  in  the  kidney  for  years 
without  giving  rise  to  serious  symptoms,  but  this  is  the  exception.  The 
chronic  nephritis  which,  to  some  extent,  always  follows  the  presence  of 
a  stone,  may  produce  such  atrophy  as  to  practically  destroy  the  secret- 
ing function  of  the  organ.  When  infection  takes  place,  the  patient  is 
subject  to  all  the  dangers  and  sequelse  of  a  septic  kidney.  One  of  the 
most  dangerous  complications  which  may  occur  is  sudden  suppression 
of  the  urine  or  calculous  anuria.  This  is  due  to  a  stone  suddenly 
blocking  up  the  ureter.  It  is  more  likely  to  occur  when  both  kidneys 
are  affected.  In  unilateral  stone,  the  suppression  in  the  opposite 
kidney  is  due  to  reflex  action  but,  in  these  cases,  it  is  probable  that 
the  stoneless  kidney  is  always  the  seat  of  pathologic  changes,  such  as 
chronic  nephritis,  atrophy,  cystic  degenerations,  etc. 

In  making  the  diagnosis,  it  is  often  difficult  to  determine  on  which 
side  the  obsti'iiction  has  taken  place.  Previous  knowledge  of  the  case 
may  be  of  assistance,  otherwise  one  must  depend  upon  the  history  of 
pain  and  the  presence  of  tenderness.    The  danger  of  this  complication 


780  ^   TEXT-BOOK  OP  GYNECOLOGY 

wall  be  appreciated  when  it  is  stated  that  the  mortality  in  cases  not 
operated  on  is  about  70  per  cent. 

Treatment. — The  acute  paroxysms  of  renal  colic  should  be  treated 
by  the  hot  bath  for  its  relaxing  effect,  and  the  administration  of  hypo- 
dermatic injections  of  morphine.  It  may  be  necessary  at  times  to  resort 
to  the  inhalation  of  chloroform.  The  possibility  of  dissolving  a  stone 
once  formed  in  the  kidney  is  quite  remote.  The  administration  of 
large  quantities  of  distilled  water  for  a  considerable  period  of  time  is 
perhaps  the  most  beneficial.  The  common  mineral  waters  and  alkaline 
springs  recommended  for  this  purpose  are  usually  without  benefit,  and 
may  even  cause  an  increase  in  the  size  of  the  stone  by  deposits  induced 
by  the  excessive  alkalinity  of  the  urine  maintained  (Eovsing).  Her- 
mann recommended  the  use  of  glycerine  in  doses  of  50  to  100  grammes 
a  day,  but  Senator  cautions  against  its  use  on  account  of  the  hematuria 
which  it  may  induce.  When  the  kidney  is  septic,  urotropin  or  cystogen 
in  doses  of  half  a  gramme  (about  7^  grains)  three  or  four  times  daily, 
will  be  of  benefit  in  so  far  as  they  inhibit  the  growth  of  the  microbes, 
and  thus  prevent  the  decomposition  of  the  urine. 

While  these  means  may  aid  somewhat  in  washing  out  gravel  or  small 
stones  from  the  kidnev,  when  a  stone  too  large  to  pass  the  ureter  once 
forms,  relief  is  only  to  be  expected  through  surgical  intervention.  Nor 
should  operation  be  delayed,  for  the  dangers  of  a  septic  kidney  are 
great,  and  the  longer  a  stone  remains,  the  more  pronounced  are  the 
changes  produced  in  the  kidney.  The  choice  of  operation  will  be  be- 
tween nephrolithotomy,  nephrostomy  and  nephrectomy.  In  an  aseptic 
kidney,  with  a  so-called  primary  stone,  nephrolithotomy  is  the  proper 
operation.  In  the  presence  of  sepsis,  with  pyelitis,  nephropyosis,  or 
abscesses  in  the  parenchyma,  in  addition  to  the  removal  of  the  stones, 
drainage  will  have  to  be  established  (nephrostomy).  The  ureter  should 
always  be  examined  and  its  patency  determined.  Should  obstruction  be 
found,  it  should  be  removed,  if  possible,  and  a  free  communication 
between  the  pelvis  and  ureter  established.  Should  this  be  neglected 
or  impossible  of  accomplishment,  a  permanent  urinary  fistula  is  almost 
certain  to  follow  the  operation.  Primary  nephrectomy  for  stone  is 
seldom  advisable.  The  opposite  kidney  must  be  known  to  be  healthy, 
and  the  affected  one  so  destroyed  as  to  be  beyond  repair,  to  warrant  the 
operation.  It  is  better  to  do  a  primary  nephrostomy  with  a  secondary 
nephrectomy  should  it  be  necessary.  The  combined  mortality  of  the 
two  operations  is  less  than  that  of  primary  nephrectomy  under  the 
conditions  usually  presented  in  bad  cases  of  septic  nephrolithiasis. 

In  anuria  from  calculus  an  attempt  may  be  made,  under  favourable 
circumstances,  to  dislodge  the  stone  by  means  of  the  ureteral  boiigie. 
Should  this  fail,  nephrostomy  should  be  performed.  In  case  no  stone 
is  found  in  the  first  kidney  operated  on,  the  other  should  be  opened 
at  once. 

Tumours  of  the  Kidney. — When  speaking  of  tumours  of  the  kidney, 
we  must  confine  ourselves  to  true  neoplasms,  to  the  exclusion  of  such 


THE  FEMALE   URINARY   APPARATUS  781 

conditions  as  nephrocystosis,  nephropyosis,  etc.  These,  wliile  giving 
rise  to  a  "  kidney  tumour  "  in  a  purely  clinical  sense,  are,  of  course,  not 
true  new  growths  in  the  strict  application  of  the  word.  What  we  find 
in  the  older  medical  literature  on  renal  tumours  is  almost  entirely 
worthless,  since,  in  these  reports,  every  swelling  is  spoken  of  under  the 
head  of  kidney  tumour,  and  even  the  true  neoplasms,  in  the  absence  of 
a  proper  microscopic  examination,  were  generally  classified  very  inaccu- 
rately. Consequently,  clinical  indications  were  drawn  without  proper 
basis  and  practical  conclusions  were  utterly  unreliable.  Only  the  last 
few  years  have  brought  some  system  into  the  unsatisfactory  chaos.  In 
certain  respects,  the  permanent  kidney  is  a  very  peculiar  organ.  It  is 
preceded  in  embryonic  development  by  two  temporary  organs,  the 
pronephros  and  the  "  urniere,"  or  Wolffian  body.  These  structures  and 
attached  portions  of  the  suprarenal  capsule  give  rise  to  embryonic  rem- 
nants which  may  become  included  in  the  permanent  kidney  and  fur- 
nish a  fertile  matrix  for  subsequent  neoplastic  formations. 

Pathology. — All  kinds  of  tumours  may  develop  in  the  kidney.  Be- 
side the  ordinary  types  of  connective  tissue  and  epithelial  neoplasms, 
benign  as  well  as  malignant,  we  find  in  the  kidney  two  peculiar  kinds 
of  tumours  which  are  of  particular  pathological  interest,  the  hyper- 
nephroma and  the  mixed  renal  tumours. 

Neoplasms  of  the  kidney,  according  to  some  authors,  occur  more 
frequently  in  the  male  than  in  the  female.  This,  however,  is  denied  by 
Kelynack  {Renal  Growth,  Edinburgh  and  London,  1898),  whose  col- 
lection of  142  cases  shows  70  tumours  in  males  and  73  cases  in  females. 
Birch-Hirschfeld  affirms  that  in  children  renal  neoplasms  are  more 
frequently  found  in  the  female  than  in  the  male  sex.  Eenal  tumours 
are  found  at  all  ages.  The  greatest  number  occur  before  the  tenth  year 
of  life.  Of  White  and  Martin's  459  tabulated  cases,  157  were  observed 
in  infants  and  children  up  to  two  years  of  age.  In  size,  these  tumours 
vary  from  small  nodules  to  growths  of  from  30  to  40  pounds  in  weight. 
In  shape,  renal  tumours  often  preserve  the  outlines  of  the  kidney,  even 
when  large.  At  other  times,  the  kidney  shape  is  entirely  lost  and  the 
mass  becomes  irregular  and  nodular.  Of  the  benign  connective-tissue 
tumours,  the  fibroma  is  generally  small,  hard  and  round,  or  elliptical. 
Occasionally  larger  fibromata  have  been  observed.  The  small  fibromata 
frequently  found  on  post-mortem  examination  are  most  probably  not 
true  neoplasms,  but  the  remnants  of  focal  interstitial  inflammatory 
processes.  Lipomata  of  the  kidney  are  rare,  but  a  small  number  of  cases 
has  been  reported.  Angeiomata  have  been  sometimes  found,  but  most 
cases  formerly  described  as  such  were  very  vascular  sarcomata. 

Sarcoma  is  probably  the  most  frequent  of  all  kidney  tumours.  It 
is  found  in  foetal  life,  in  infancy  and  childhood,  and  in  adolescence. 
The  importance  and  frequency  of  sarcoma  of  the  kidney  in  childhood 
has  been  pointed  out  by  Jacobi  in  a  number  of  articles.  Herzog  be- 
lieves that  renal  sarcoma  is  more  frequently  found  in  female  than  in 
male  children.   "Kenal  sarcoma  occurs  as  a  capsular,  a  parenchymatous. 


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A  TEXT-BOOK  OF  GYNECOLOGY 


and  a  hilum  growth.     It  may  also  primarily  arise  in  the  suprarenal 

capsule,  to  grow  secondarily  into  the  kidney.     Histologically,  we  find 

round  and  spindle-celled 
growths,  or  the  cells  are 
of  mixed  type  and  char- 
acter. The  sarcoma  de- 
picted in  Fig.  313,  re- 
moved by  operation  from 
a  child  nine  months  old 
by  Harris,  and  studied  as 
to  its  histology  by  Her- 
zog,  was  of  such  a  mixed 
type  and  showed  very 
heterologous  connective- 
tissue  elements.  The  pro- 
liferation of  tumour  cells 
is  well  shown  in  a  section 
(Fig.  31-i)  prepared  by 
Herzog.  It  was  for- 
merly believed  that  ade- 
nomata were  among  the 
most  frequent,  if  not  the 
most  frequent,  of  renal 
tumours.  But  most  of 
the  cases  formerly  re- 
ported as  adenomata  did 
not  belong  to  this  class  of 

neoplasms,  but  to  the  hypernephromata  (see  postea.)     True  nonmalig- 

nant  adenomata  occur  as  nodules  varying  in  size  from  that  of  a  millet 

seed  to   that   of   a   hazelnut. 

They     are     sharply     defined 

from  the  surrounding  normal 

tissue.      Histologically,    they 

show  either  an  alveolar  or  a 

tubular  type.    It  is  sometimes 

difficult    to    distinguish    be- 
tween a  benign  adenoma  and 

an   early  adenocarcinoma, 

and  the  more  so  since  some 

renal     adenomata     primarily 

benign,     undergo     secondary 

malignant  degeneration. 

Kelynack      describes      as 

such     forms    the     malignant 

papuliferous   cystadenoma   of 

the   kidney.     Epithelial  neo- 
plasms which,  from  the  very 


Fig.  313. — "The  sarcoma  reriioved  by  operation  from  a 
child  nine  months  old  by  Harris." — Herzog. 


Fig.  314. — "  The  proliferation  of  tumour  cells  is 
well  shown  in  a  section."— Heezog. 


THE  FEMALE   URINARY   APPARATUS 


7S3 


start,  are  malignant  in  character,  in  other  words  typical  carcinomata, 
are  not  common  in  the  kidney.  They  may  be  either  soft  or  hard, 
and  often  lead  to  considerable  enlargement  of  the  kidney  affected. 
An  embryonal  renal  adenosarcoma,  mixed  tumour,  59  centimetres  in 
circumference,  was  removed  by  Dr.  Denslow  Lewis  from  a  child  sixteen 
months    old    (Fig.    315). 

The  histogenesis  of 
mixed  tumours  of  the  'kid- 
ney, or  embryo7ial  renal 
adenosarcomata,  was 
cleared  up  a  few  years  ago 
by  Birch-Hirschfeld,  and 
Herzog  was  the  first  to 
take  up  this  subject  in 
the  English  language. 
(Herzog:  The  Peculiar 
Mixed  Tumours  of  the 
Kidney,  Chicago  Medical 
Recorder,  1899;  Herzog 
and  Lewis:  Embryonal 
Eenal  Adenosarcoma, 
American  Journal  of  the 
Medical  Sciences,  June, 
1900.)  These  mixed  renal 
tumours  occur  very  early 
in  life,  frequently  during 
the  first  years,  though  a 
very  few  cases  have  been 
reported  in  adults.  They  grow  very  rapidly,  speedily  lead  to  general 
malignant  cachexia,  and  destroy  the  life  of  the  patient  either  with  or 
without  the  formation  of  metastases.  They  generally  first  attract  atten- 
tion by  the  increasing  size  of  the  abdomen.  These  tumours  always  de- 
velop inside  the  kidney.  The  kidney  tissue  proper,  however,  does  not 
take  part  in  the  proliferating  neoplastic  processes  but  becomes  com- 
pressed by  the  new  growth  and  the  urinif  erous  tubules,  and  their  lining 
epithelia  disappear  in  consecjuence  of  pressure  atrophy.  What  is  left  of 
the  kidney  sometimes  sits  on  the  tumour  like  a  flat  cap.  These  malig- 
nant renal  tumours  are  so  heterologous  in  their  histology  that  they  have 
been  described  as  carcinomata,  sarcomata,  endotheliomata,  rhabdomyo- 
mata,  and  under  a  variety  of  compound  names.  The  feature  common  to 
them  all  is  the  fact  that  they  present  a  mixture  of  epithelial,  adenoma- 
tous, and  connective-tissue  elements,  all  of  which  are  proliferating  in  a 
most  extensive  embryonal  manner  (Fig.  31G). 

These  tumours  very  frequently  contain  striated  muscle  fibres  which 
sometimes  are  so  numerous  that  such  new  growths  were  formerly  de- 
scribed as  rhabdoinyomata  or  Hiabfloiiiyosarcoiiiata.  Fig.  317  is  from  a 
section  of  mixed  tumour,  the  rhabdomyomatous  part  showing  embryonal 


Fig.   315.  —  "An    embryonal    renal    adenosarcoma 
removed  by  Dr.  Denslow  Lewis." — Herzog. 


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A  TEXT-BOOK  OF   GYNECOLOGY 


Fig.  316. — "Tliuy  pnj.-M.-iit  a  mixture  of  epitlielial, 
adenomatous,  and  connective-tissue  elements." — 
Harris  (page  783). 


striated  muscle  cells.  They  do  not  tend  to  form  early  metastases,  but, 
on  the  contrary,  lead  to  the  latter  only  after  the  growth  has  become  so 
very  large  that  it  has  broken  by  pressure  through  the  capsule.     The 

neighbouring  lymphatics  are 
not  affected  even  when  the 
epithelial  type  predominates. 
Several  theories  have  been 
advanced  as  to  the  origin 
and  the  histogenesis  of  these 
mixed  tumours.  Herzog  {loc. 
cit.)  has  advanced  the  follow- 
ing theory: 

"  The  nephrotome  in 
early  embryonic  develop- 
ment is  not  cut  off  at  the 
normal  site,  but  in  such  a 
manner  that  a  part  of  the 
myotome  is  severed  from  the 
main  mass  and  remains  in 
conection  with  the  nephro- 
tome. The  separation  may 
take  place  so  that  only  a  part 
of  the  myotome  proper  is  cut 
off,  or  a  part  of  the  sclerotome  may  likewise  be  taken  along.  If  the  former 
is  the  case,  we  have  the  matrix  for  striated  muscle  fibres  only;  if  the  latter 
occurs,  we  have  also  the  matrix 
for  cartilage.  If,  now,  we  as- 
sume that  a  part  of  the  ne- 
phrotome (Wolffian  body)  to 
which  tissues  of  the  myotome 
have  become  adherent  by  an 
abnormal  process  of  embry- 
onic separation,  becomes  in- 
cluded in  the  permanent  kid- 
ney, we  have  a  matrix  con- 
taining all  those  embryonic 
elements  which  occur  in  the 
mixed  renal  tumours,  name- 
ly, striated  muscle  fibres,  car- 
tilage, other  connective-tis- 
sue elements,  and  epithelial 
glandular  structures.  The 
latter,  of  course,  are  derived 
from  the  excretory  tubules  of 
the  nephrotome." 

Hypernephromata. — Certain  renal  tumours   described  formerly   as 
lipomata  or  adenomata  are  now  known  to  be   derived  from  supra- 


FiG.  317. — ".  .  .  A  section  of  mi.xed  tumour,  the 
rhabdomyomatous  part  showing  embryonal  stri- 
ated muscle  cells." — Herzog  (page  783). 


THE   FEMALE   URINARY  APPARATUS 


785 


renal  tissue  misplaced  within  the  kidney  during  embryonic  devel- 
opment. These  tumours  were  called  by  Grrawitz^  who  first  recognised 
their  true  nature,  Struma  suprarenalis  lipomatodes  aberrans.  They 
are  now  generally  known  under  the  name  of  hypernephromata 
(Fig.  318). 

The  included  aberrant  suprarenal  tissue  may  develop  into  non- 
malignant  tumours.    Even  the  latter  are  generally  slow  in  their  growth, 
but  they  usually  give  rise  to  metastases.    These  new  growths  generally 
give  rise  to  a  dull  pain, 
and    frequently    produce 
periodical    intermittent 
hematuria  in  consequence 
of  their  great  vascularity. 

Histologically,  they 
show  a  tissue  which  is  an 
atypical  imitation  of  the 
structure  of  the  supra- 
renal capsule.  The  tu- 
mour cells  are  particularly 
often  found  in  an  arrange- 
ment very  much  similar  to 
that  seen  in  the  zona  fas- 
ciculata  of  the  adrenal 
gland  (Fig.  319).  The 
cells  show  a  universal 
marked  tendency  to  un- 
dergo fatty  degeneration, 
and  glycogen  is  likewise 
often  found  (Fig.  330). 

Symptomatology  and 
Diagnosis.  - — ■  The  symp- 
toms of  renal  neoplasms 
are  very  meagre,  so  much 

so,  that  it  is  usually  impossible  to  make  a  diagnosis  as  to  the  par- 
ticular kind  of  tumour  present.  Nearly  50  per  cent  of  the  new 
growths  occur  in  children  under  five  years  of  age.  The  appearance 
of  an  enlargement  in  the  region  of  the  kidney  is,  in  the  majority 
of  cases,  the  first  intimation  of  trouble.  A  rapidly  growing  tumour 
of  the  kidney  in  a  child  is  a  sarcoma  or  a  so-called  "  mixed " 
tumour.  They  seldom  give  rise  to  urinary  symptoms  although, 
in  a  few  cases,  some  hematuria  has  been  noted.  Pain  is  uncommon 
but  the  tumour  may  be  tender.  The  child  may  play  about  with 
little  discomfort  until  within  a  few  weeks  of  its  death.  The  tu- 
mour often  becomes  of  largo  size  causing  great  distention  of  the 
abdomen.  It  may  be  so  smootli  and  soft  as  to  simulate  very  closely 
a  iluctuating  mass.  When  very  large,  symptoms  due  to  pressure  or 
distention  may  be  observed.  Kapid  emaciation  and  anannia  are  marked, 
51 


Fig.  318. — "  Hypernephromata." — Herzog. 


786 


A   TEXT-BOOK  OF   GYNECOLOGY 


and  death  takes  place  by   exhaustion  in  from  six  to   eight  months 
or  a  year;  it  is  rarely  delayed  vintil  two  years. 

In  the  adult,  hematuria 


Jll 


Fig.  319. — "  The  tumour  cells  are  .  .  .  found  in  an 
arrangement  very  much  similar  to  that  seen 
in  the  zona  fasciculata  of  the  adrenal  gland." 
— Herzog  (page  785). 


is  a  much  more  frequent 
symptom  of  tumour  than  in 
the  child,  as  it  is  present  in 
malignant  tumours  in  from 
70  to  80  per  cent  of  the  cases 
(Guyon).  It  is  spontaneous 
in  character,  appears  at  ir- 
regular intervals,  is  painless, 
and  is  usually  discovered  by 
accident.  In  the  majority  of 
the  cases,  a  tumour  is  already 
present  when  the  hematuria 
is  first  observed,  but  hema- 
turia may  exist  for  some  time 
before  any  enlargement  can 
be  felt.  Pain  can  not  be  said 
to  be  a  characteristic  symp- 
tom of  renal  tumours,  but  a 
vague,  dull  ache  in  the  lum- 
bar region  has  been  frequent- 
ly observed.  Carcinoma  of  the  pelvis  shows  a  great  tendency  to 
extend  to  the  ureter.  This  causes  an  obstruction  to  the  free  escape 
of  the  urine  and  leads  to  the  development  of  a  nephrydrosis  or 
nephrohematosis.  The  dura- 
tion of  malignant  tumours  \llii^  \  i 
in  the  adult  is  much  longer, 
on  the  average,  than  in  the 
child,  as  it  is  usually  from 
two  to  three  or  even  five 
years  before  death  occurs. 
In  tumours  of  the  adrenals, 
hypernephroma,  and  carci- 
noma, hematuria  is  rare. 
The  kidney  may  often  be  dis- 
tinctly felt  displaced  down- 
ward by  the  tumour  enlarg- 
ing from  above.  In  tumours 
that  destroy  the  adrenals, 
such  as  the  carcinomata, 
marked  loss  of  strength, 
physical  depression,  and  lan- 
guor, are  quite  characteristic 

symptoms  (Eamsay).     Some  bronzing  of  the  skin  has  been  observed 
a  few  times  but  does  not  appear  to  be  the  rule.     There  are  no  char- 


FiG.  320.—"  The  cells  show  a  universal  tendency  to 
undergo  fatty  degeneration." — Hebzog  (page  785). 


THE  FEMALE  URINARY   APPARATUS  787 

acteristic  symptoms  by  which  the  rather  rare  benign  tumours  can  be 
distinguished. 

The  treatment  of  tumours  of  the  kidney  is  removal  by  nephrectomy. 
Unfortunately,  the  onset  of  the  malignant  tumours  is  so  insidious 
that  considerable  progress  has  usually  already  been  made  when  a  diag- 
nosis is  established.  The  remote  results  in  the  sarcomata  of  early 
childhood  are  not  very  encouraging,  as  very  few  cases  indeed  are  on 
record  which  have  survived  the  operation  for  three  years.  Owing  to 
the  slower  course  of  these  growths  in  the  adult,  the  remote  results  are 
better.  Wagner  has  collected  34  cases  surviving  the  operation  for  more 
than  two  years.  The  immediate  mortality  of  nephrectomy  for  carci- 
noma is  24  per  cent  (Heresco).  Partial  nephrectomy  has  been  per- 
formed a  few  times  for  supposed  benign  growths,  usually  with  recur- 
rence. As  it  is  so  difficult  to  determine  whether  a  tumour  is  benign  or 
malignant,  the  advisability  of  partial  nephrectomy  is  questionable. 

Operations  on  the  Kidney. — There  are  three  principal  operations 
performed  on  the  kidney,  namely:  1.  Nephropexy  (nephrorrhaphy)  or 
fixation  of  a  movable  kidney.  2.  Nephrotomy,  the  cutting  into  a  kid- 
ney, including  pyelotomy,  the  cutting  into  the  pelvis  of  the  kidney 
for  exploratory  purposes,  for  the  removal  of  stone  (nephrolithotomy) 
or  for  the  establishment  of  drainage  (nephrostomy).  3.  Nephrec- 
tomy, partial  (resection),  and  complete.  There  are  two  routes  by  which 
the  kidney  may  be  reached — the  anterior,  or  transperitoneal;  and  the 
posterior,  or  lumbar.  The  advantages  claimed  for  the  transperitoneal 
route  are:  That  it  permits  palpation  of  the  opposite  kidney  and  affords 
easier  access  to  the  pedicle  in  nephrectomy  for  large  tumours.  These 
advantages,  however,  have  been  overestimated.  Palpation  of  the  kid- 
ney gives  little  knowledge  beyond  the  mere  fact  of  its  existence,  which 
fact  can  now  be  learned  by  other  means;  and  the  pedicle  can  usually  be 
just  as  easily  reached  from  behind  as  from  the  front.  On  the  other  hand, 
the  danger  of  infection,  the  difficulty  of  closing  the  peritoneum  pos- 
teriorly, and  the  necessity  of  providing  lumbar  drainage,  have  led 
surgeons  to  abandon  the  transperitoneal  route  except  perhaps  in  rare 
cases  of  misplaced  or  displaced  and  abnormally  fixed  kidneys.  A  num- 
ber of  incisions  have  been  proposed  for  reaching  the  kidney  through 
the  lumbar  region,  as  the  longitudinal,  oblique,  rectangular,  and 
transverse.  The  distance  from  the  twelfth  rib  to  the  crest  of  the  ilium 
is  so  short  that  the  longitudinal  incision  seldom  affords  sufficient  work- 
ing space.  The  rectangular,  or  Konig's  incision,  starting  from  the  tip 
of  the  twelfth  rib  and  extending  obliquely  downward  toward  the  an- 
terior superior  spine  of  the  ilium,  then  suddenly  curving  forward  and 
upward,  and  the  transverse  incision  just  below  the  twelfth  rib,  are 
chiefly  employed  for  the  removal  of  large  tumours;  while  the  oblique 
incision,  extending  from  just  below  and  posterior  to  the  tip  of  the 
twelfth  rib,  downward  and  forward,  is  the  one  usually  employed  in 
nephropexy,  nephrotomy,  etc.  If  the  oblique  incision  is  started  a 
little  in  front  of  the  tip  of  the  twelfth  rib,  and  is  extended  downward  in 


788  A  TEXT-BOOK  OF  GYNECOLOGY 

the  direction  of  the  fibres  of  the  external  oblique,  it  can  be  made  a 
muscle-splitting  incision,  the  fibres  of  the  external  oblique  being  sepa- 
rated longitudinally,  and  those  of  the  internal  oblique  transversely, 
to  the  cutaneous  incision.  The  kidney  can,  in  this  manner,  be  reached 
without  dividing  muscular  fibres,  thus  minimizing  the  danger  of  ven- 
tral hernia.  The  muscle-splitting  incision  will  be  found  preferable  in 
the  majority  of  operations  on  the  kidney. 

Nephropexy  or  Nephrorrhaphy. — The  kidney  having  been  exposed 
by  the  muscle-splitting  incision,  all  the  perirenal  fat  should  be  care- 
fully removed.  In  doing  this  the  prerenal  fascia  should  be  preserved. 
Two  flaps  of  the  transversalis  fascia,  about  5  to  6  centimetres  in 
length,  are  now  turned  back  from  2  to  3  centimetres,  one  on  either 
side  of  the  incision.  The  anterior  flap  should  be  stitched  with  cat- 
gut to  the  prerenal  fascia  and  to  the  anterior  surface  of  the  kidney, 
and  the  posterior  flap  in  a  similar  manner  to  the  posterior  surface  of 
the  kidney.  We  thus  have  the  kidney  flrmly  fixed  to  the  posterior 
abdominal  wall  by  two  flaps  of  fascia.  The  flaps  should  be  made  as  high 
up  as  possible,  and  fixed  to  the  kidney  in  such  a  manner  that  the  pelvis 
and  ureter  shall  have  a  proper  direction  and  the  upper  portion  of  the 
latter  be  free  from  kink  or  twist  that  might  offer  obstruction  to  the 
free  escape  of  the  urine.  That  portion  of  the  kidney  between  the 
attached  flaps  will  lie  in  contact  with  denuded  muscle  when  the  wound 
is  closed.  The  capsula  fibrosa  may  be  scarified  to  excite  a  freer  pro- 
liferation of  connective  tissue.  If  thought  desirable,  the  kidney  may  be 
transfixed  by  two  or  more  catgut  sutures  to  hold  it  more  firmly  in  con- 
tact with  the  denuded  muscle,  or  it  may  be  denuded  of  its  fibrous  cap- 
sule. The  wound  is  then  closed  and  the  patient  kept  in  the  recumbent 
position  for  three  or  four  weeks,  to  allow  sufficient  time  for  firm  adhe- 
sion to  take  place.  It  has  been  recommended  by  some  simply  to  expose 
the  kidney  freely,  draw  it  up  and  pack  the  wound  with  gauze  until 
granulations  are  well  established,  then  allow  the  wound  to  close. 
Preference,  however,  must  be  given  to  a  closed  wound  with  primary 
union.  The  numerous  attempts  to  fix  the  kidney  to  the  ribs  by  a 
variety  of  sutures  have  little  to  commend  them.  The  success  of  the 
operation,  so  far  as  curing  the  symptoms  is  concerned,  depends,  not  so 
much  upon  fixing  the  kidney  as  high  up  as  possible,  as  upon  fixing  it 
in  such  a  position  that  its  pedicle  shall  be  free  and  the  urine  have 
easy  and  unobstructed  escape. 

Nephrotomy. — Expose  the  kidney  by  the  muscle-splitting  incision. 
If  the  operation  is  one  of  exploration  or  for  the  removal  of  stone,  free 
the  organ  so  that  it  can  be  palpated  throughout,  pelvis  included.  It 
should  be  opened  along  its  posterior  border.  The  incision,  which  may 
be  made  with  an  ordinary  scalpel,  should  extend  into  the  pelvis  and 
may  be  as  long  as  deemed  necessary.  As  hemorrhage  is  likely  to  be 
profuse,  the  kidney  should  never  be  incised  unless  under  perfect  con- 
trol of  the  operator.  The  organ  should  be  grasped  in  the  hand  and  the 
incision  made  between  the  thumb  and  fingers.    In  this  manner,  pres- 


THE   FEMALE   URINARY   APPARATUS  789 

sure,  which  readily  controls  the  hemorrhage,  is  easily  applied,  and  is 
much  to  be  preferred  to  clamping  the  pedicle  with  forceps.  The  in- 
terior of  the  pelvis  may  now  be  explored,  and  calculi,  if  present,  re- 
moved. It  should  then  be  freely  irrigated  with  hot  normal  salt  solu- 
tion to  check  oozing  and  free  it  of  blood  clots  or  debris  which  might 
form  nuclei  for  new  stone  formations.  If  not  septic,  the  kidney  should 
be  closed  by  deep  and  superficial  catgut  sutures  and  the  external  wound 
closed  as  usual.  When  the  object  of  the  nephrotomy  is  drainage  of 
a  suppurating  organ,  the  abscess  cavity  is  opened,  cleansed  by  irriga- 
tion, a  good-sized  rubber  drainage  tube  inserted,  and  the  wound  packed 
with  gauze. 

Nephrectomy. — The  oblique  muscle-splitting  incision  is  suitable  for 
kidneys  of  moderate  size.  In  very  large  tumours,  Konig's,  or  the  trans- 
verse incision,  which  is  particularly  applicable  in  children,  will  give 
more  room.  In  malignant  tumours,  it  is  advisable  to  remove  as  much 
as  possible  of  the  fatty  capsule  with  the  kidney.  In  nonmalignant 
cases,  the  kidney  is  loosened  from  its  surrounding  tissue  until  the 
pedicle  is  reached,  when,  if  accessible,  the  vessels  and  ureter  should  be 
separately  ligated  with  catgut.  Should  the  presence  of  the  kidney 
interfere  with  the  ligation  of  the  pedicle,  an  angular  clamp  may  be 
placed  on  the  vessels  and  the  kidney  removed.  Should  it  still  be  found 
impossible  to  ligate  the  vessels  satisfactorily,  the  clamp  may  be  left 
in  position  for  about  twenty-four  hours,  when  it  may  be  removed  with 
safety.  In  septic  cases,  the  upper  end  of  the  ureter  should  be  fixed 
into  the  lower  angle  of  the  wound.  When  there  is  considerable  peri- 
nephritis fibrosa,  as  is  common  in  tuberculosis  and  other  chronic  septic 
conditions,  it  may  be  very  difficult,  or  even  impossible,  to  separate  the 
mass  from  the  surrounding  organs  without  great  danger  of  injury,  par- 
ticularly to  the  colon  and  vena  cava.  Harris  has  seen  the  colon  so  in- 
jured in  this  manner  as  to  lead  to  the  formation  of  a  faecal  fistula.  In 
attempting  to  separate  the  inner  layer  of  the  mesocolon,  there  is 
also  danger  of  clamping  or  ligating  one  of  the  colic  arteries,  which  may 
produce  sloughing  of  a  portion  of  the  colon.  In  these  cases  of  peri- 
nephritis fibrosa,  it  is  better  to  cut  directly  through  to  the  kidney  tissue 
itself,  and  to  enucleate  the  kidney  from  its  fibrous  capsule.  The  pedicle 
may  be  so  involved  in  the  fibrous  mass  as  to  render  ligation  impossible. 
It  will,  therefore^  be  necessary  to  apply  a  clamp  and  allow  it  to  remain 
for  twenty-four  hours.  The  wound  should  be  packed  with  gauze  and 
the  clamp  protected  by  the  dressings.  If  tuberculous  deposits  are  found 
in  the  ureter,  this  canal  should  be  dissected  out  as  far  down  as  possible 
or  until  all  the  diseased  tissue  has  been  removed.  In  all  operations 
on  the  kidney,  and  particularly  after  nephrectomy,  the  danger  of  de- 
ficient elimination  by  the  opposite  kidney  should  always  be  borne  in 
mind.  It  is  necessary,  therefore,  to  siipply  these  patients  with  an 
abundance  of  fluid,  either  by  filling  the  colon  with  normal  salt  solution 
or  by  injecting  it  subcutancously. 


CHAPTEK  XLIX 

THE  FEMALE  URINARY  APPARATUS  (Continued) 

Cystitis  :  Etiology,  bacteriology,  pathologic  changes,  symptomatology  and  diag- 
nosis, treatment  —  Hypei-^emia,  treatment  —  Foreign  bodies  in  the  bladder, 
treatment  —  Tumors  of  the  bladder:  Symptomatology  and  diagnosis,  treat- 
ment— Urethral  caruncle,  treatment — Carcinoma  of  the  urethra,  treatment — 
Sarcoma  of  the  urethra — Diverticula  of  the  urethra,  treatment — Strictures  of 
the  urethra  —  Prolapse  of  the  urethra,  treatment  —  Foreign  bodies  in  the 
urethra — Dilatation  of  the  urethra,  treatment — The  urachus — Vesieo-umbilical 
fistula,  treatment — Cysts  of  the  urachus. 

Cystitis  is  an  inflammatory  condition  due  to  the  invasion  of  the 
walls  of  the  bladder  by  pathogenic  microbes.  The  urine  frequently 
contains  microbes  but  this  is  not  in  itself  sufficient  to  produce  a  cystitis. 
It  is  absolutely  necessary  that  the  microbes  should  lodge  and  develop 
either  upon  or  within  the  walls  of  this  organ,  before  an  inflammatory 
condition  can  be  established.  The  etiology,  therefore,  of  cystitis  may 
be  considered  under  two  heads:  1.  Those  influences  that  predispose  to 
the  lodgment  and  development  of  the  microbes;  and  2.  The  manner 
in  which  the  microbes  gain  entrance  to  the  bladder.  One  of  the  most 
frequent  predisposing  causes  of  infection  is  congestion.  This  greatly 
reduces  the  resisting  power  of  the  bladder  and  may  be  induced  in  a 
variety  of  ways.  Common  among  these  may  be  mentioned  exposure  to 
cold;  overdistention  of  the  bladder  from  prolonged  retention  of  the 
urine;  obstruction  to  the  free  escape  of  the  urine  due  to  stricture  of 
the  urethra;  intravesical  or  urethral  tumours;  displacement  of  the 
bladder  from  extra-vesical  tumours,  uterine  displacements,  cystocele, 
etc.;  traumata,  such  as  contusion  of  the  bladder  or  prolonged  pressure 
from  the  child's  head  during  labour;  contusion  from  external  violence 
or  accidental  or  unavoidable  injury  by  the  surgeon  during  operations 
on  neighbouring  parts;  internal  trauma  produced  by  foreign  bodies, 
either  developed  within  (vesical  calculi),  or  introduced  by  the  patient 
from  without  (hairpins,  pieces  of  pencils,  chewing  gum,  etc.),  or  by 
the  physician  or  nurse  (catheter,  sound,  cystoscope,  etc.);  abnormal 
states  of  the  urine  due  to  the  elimination  of  irritating  substances  intro- 
duced from  without  (cantharides,  turpentine,  oil  of  sabine,  etc.),  or 
developed  within  the  body  (toxines  from  intestinal  disturbances,  acute 
infectious  diseases,  etc.).  The  bladder  participates  somewhat  in  the 
general  congestien  of  the  pelvic  organs  accompanying  menstruation, 
790 


THE   FEMALE   URINARY   APPARATUS  791 

and  this  congestion  may  be  greatly  increased  by  sudden  suppression 
of  this  function. 

The  second  essential  factor  in  the  production  of  the  inflammation, 
namely,  the  pathogenic  microbes,  may  gain  entrance  to  the  bladder: 
1.  Through  the  urethra;  2.  From  the  kidneys  with  the  urine;  3.  From 
contiguous  parts;  4.  From  the  blood.  The  most  common  route  is  un- 
doubtedly along  the  urethra.  The  shortness  of  this  canal  in  women 
makes  it  much  easier  for  microbes  to  enter  the  bladder  through  it  in 
them  than  in  men.  Gonorrhoeal  infection,  which  always  affects  the 
urethra,  may  extend  to  the  bladder.  Infections  from  other  microbes 
involving  the  vulva,  vestibule,  or  vulvo-vaginal  glands,  may  likewise 
extend  along  the  urethra.  The  germs  may  be  carried  to  the  bladder  on 
septic  catheters  or  other  instruments.  Even  a  sterilized  catheter  may 
carry  germs  that  are  within  or  about  the  meatus  into  the  bladder. 
The  bruised  and  congested  condition  of  the  bladder  following  con- 
finement or  operations  on  the  generative  organs,  makes  the  introduction 
of  germs  by  the  catheter  particularly  liable  to  excite  a  cystitis.  The 
greatest  care  should,  therefore,  always  be  taken  in  cleansing  the  meatus 
and  adjoining  parts,  and  in  sterilizing  and  introducing  the  catheter 
under  these  conditions.  The  patient  herself  may  introduce  the  germs 
on  all  sorts  of  foreign  bodies  used  for  masturbating  purposes  or  when 
mentally  deranged.  Germs  frequently  reach  the  bladder  by  descending 
with  the  urine  from  the  kidneys.  It  is  not  necessary  that  the  kidneys 
be  diseased,  as  it  is  well  known  that  these  organs  frequently  eliminate 
microbes  from  the  blood  without  themselves  being  involved  thereby. 
This  may  take  place  in  the  acute  infectious  diseases,  in  diseases  of  the 
intestinal  tract,  and  in  suppurative  conditions  in  other  portions  of  the 
body.  The  kidneys,  however,  may  be  the  primary  point  of  infection, 
as  in  pyelitis,  nephropyelitis,  etc.,  and  this  is  particularly  common  in 
tuberculous  infection.  The  transmission  of  microbes  to  the  bladder  by 
contiguity  may  occur  in  intrapelvic  suppurative  conditions  such  as 
pyosalpinx,  circumscribed  suppurative  peritonitis,  infections  of  the 
uterus,  etc.  Such  purulent  collections  may  rupture  into  the  bladder, 
thus  carrying  infection  directly.  Infection  may  come  from  the  rectum, 
from  a  loop  of  inflamed  bowel  that  has  become  adherent  to  the  bladder, 
or  even  from  the  appendix,  as  Harris  has  seen  in  one  case.  The  intro- 
duction of  germs  by  direct  trauma,  as  in  bullet  wounds,  punctured 
wounds,  etc.,  is  possible  but  not  common.  Lastly  may  be  mentioned 
pure  hematogenous  infections,  where  germs  reach  the  bladder  wall 
through  the  blood,  as  either  minute  septic  emboli  or  floating  germs. 
The  normal  bladder  possesses  considerable  immunity  to  infection. 
Therefore,  in  addition  to  the  germs,  which  are  the  essential  element  of 
inflammation,  certain  of  the  above-mentioned  predisposing  conditions 
must  be  present  to  temporarily  reduce  the  resisting  power  of  the  tissues 
in  order  that  the  germs  may  lodge  and  develop  and  cystitis  be  produced. 

Barkriohf/y. — To  the  investigations  of  Eumm,  Clado,  Halle  and 
Albarran,  Krogiiis,  Escherich,  Posner,  Lewin,  Melchoir,  Eovsing  and 


792  A  TEXT-BOOK  OP   GYNECOLOGY 

others,  is  due  our  knowledge  of  the  bacteriology  of  cystitis.  Many 
varieties  of  bacteria  have  been  found  in  the  bladder.  The  one  most 
frequently  present  is  the  colon  bacillus.  It  reaches  the  bladder,  usually, 
from  the  kidneys  with  the  urine,  but  may  pass  directly  from  the  bowel 
to  the  bladder  when  these  two  organs  are  connected  by  inflammatory 
exudate  or  adhesions.  It  may  also  enter  through  the  urethra.  This  is 
most  common  in  very  young  girls,  where,  in  the  presence  of  acute 
intestinal  disturbances,  from  lack  of  cleanliness,  a  vulvar  inflammation 
develops  and  the  infection  extends  along  the  urethra  to  the  bladder. 
As  the  colon  bacillus  does  not  decompose  urea,  the  urine  remains  acid 
in  colon  cystitis.  The  gonococcus  almost  always  enters  the  bladder 
through  the  urethra.  This  may  occur  during  an  acute  gonorrhoea  or 
during  one  of  the  frequent  slight  exacerbations  of  a  chronic  or  latent 
infection.  Many  of  the  cases  of  cystitis  following  childbirth  originate 
in  the  latter  manner,  favoured  by  the  bruised  condition  of  the  bladder 
and  urethra  incident  to  the  labour.  The  gonococcus,  likewise,  does  not 
decompose  urea.  Of  the  ordinary  pyogenic  microbes,  the  streptococci 
are  more  frequently  found  than  the  staphylococci.  They  may  reach 
the  bladder  on  unsterilized  instruments  or  from  contiguous  suppurat- 
ing foci,  and  are  frequently  found  associated  with  tumours  of  the 
bladder,  as  the  epitheliomata,  papillomata,  etc.  The  streptococci  do 
not  decompose  urea  but  almost  all  the  staphylococci  do.  Therefore,  in 
the  presence  of  the  latter,  we  find  ammoniacal  alkaline  urine.  The 
proteus  of  Hauser  has  been  found  a  number  of  times  in  cystitis.  It  acts 
very  energetically  on  urea  and  the  urine  is  therefore  strongly  ammoni- 
acal. The  prognosis  in  infection  by  the  proteus  of  Hauser  is  unfavour- 
able, as  3  out  of  4  subjects  seen  by  Melchoir  died.  Krogius  saw  2  sub- 
jects, both  of  whom  died.  The  tubercle  bacillus  is  a  common  cause  of 
chronic  cystitis  and  usually  infects  the  bladder  from  a  tuberculous  focus 
in  the  kidney.  The  urine  in  tuberculous  cystitis  remains  acid.  Other 
bacteria  have  occasionally  been  found  in  cystitis,  but  not  with  suf- 
ficient frequency  to  demand  special  mention.  Mixed  infections  may 
likewise  occur. 

The  patliologic  clianges  produced  are  much  the  same  regardless  of 
the  particular  kind  of  microbe  present,  with  the  exception  of  the 
tubercle  bacillus  which  alone  produces  somewhat  characteristic 
changes.  Marked  difi^erences,  however,  exist  in  degree.  The  same 
variety  of  microbe  may  at  one  time  produce  the  most  extensive  changes, 
and  at  another  time  almost  none,  for  reasons  that  can  not  better  be  ex- 
pressed than  by  the  terms,  "  varying  virulence  "  on  the  part  of  the 
microbes,  and  "  power  of  resistance  "  on  the  part  of  the  bladder.  The 
changes  produced  are  hyperfemia  with  swelling  and  infiltration.  These 
may  be  circumscribed  or  difi^use.  In  the  former  case,  they  may  be  limited 
to  a  small  area  about  the  inner  orifice  of  the  urethra,  to  the  trigone,  or 
to  a  small  area  about  one  or  the  other  ureteral  orifice.  In  severe  cases, 
the  mucosa  is  considerably  swollen  and  thrown  into  folds.  It  is  soft, 
often  oedematous,  and  small  hemorrhages  are  not  infrequent.    Erosions 


THE   FEMALE   URINARY   APPARATUS  Y93 

may  occur,  particularly  on  the  folds.  Papillomatous  elevations  which 
are  soft  and  bleed  easily  on  touch  may  form.  Inflamed  areas  may 
become  covered  by  a  grayish  or  yellowish  membranelike  substance 
composed  of  pus  cells,  mucus,  bacteria,  detached  epithelial  cells,  etc., 
in  which  phosphates  may  be  deposited,  and  which  may  adhere  quite 
intimately  to  the  mucosa.  The  changes  may  extend  to  the  submucosa 
and  muscularis,  where  abscesses  may  form  that  may  rupture  into  the 
bladder  or  into  the  pericystic  tissues.  The  inflammatory  changes  may 
extend  through  the  entire  wall  of  the  bladder  producing  a  pericystitis. 
In  chronic  cases  the  muscularis  becomes  greatly  hypertrophied,  the 
walls  much  thickened,  and  the  capacity  of  the  organ  markedly  reduced. 
In  a  particularly  virulent  infection  following  childbirth  or  some  of 
the  acute  infectious  diseases,  the  mucosa  may  slough.  A  diphtheritic 
cystitis  may  likewise  occur.  In  tuberculous  cystitis  the  changes  are 
usually  circumscribed  and  appear  first  about  the  ureteral  orifices. 
Small,  slightly  elevated  tubercles,  may  be  seen,  which  undergo  casea- 
tion and  softening,  and  break  down  forming  small  ulcers.  There  may 
be  but  a  single  ulcer  or  they  may  be  multiple.  When  a  mixed  infec- 
tion is  present,  the  usual  changes  may  be  seen  in  addition  to  the 
ulcers. 

Symptomatology  and  Diagnosis. — Cystitis  manifests  itself  by  j^ain- 
ful,  frequent  urination,  and  changes  in  the  character  of  the  urine. 
The  severity  of  the  symptoms  varies  greatly.  In  acute  cystitis,  the 
desire  to  urinate  is  very  urgent  and  the  pain  accompanying  the  act  quite 
marked.  The  increased  sensitiveness  of  the  mucosa  impels  the  patient 
to  evacuate  the  bladder  so  soon  as  a  small  amount  of  urine  accumulates 
within  it,  and  the  contraction  of  the  muscle  incident  thereto  is  the 
chief  cause  of  the  pain.  In  severe  cases  it  is  necessary  to  urinate 
frequently,  sometimes  as  often  as  every  few  minutes,  day  and  night; 
and  as  the  relief  obtained  is  often  slight  or  of  short  duration,  the 
patient  is  almost  constantly  tormented  and  thus  deprived  of  much 
needed  rest  and  sleep.  In  milder  cases,  urination  may  be  necessary 
only  every  hour  or  two  during  the  day  and  two  or  three  times  at  night. 
The  pain  is  felt  deep  in  the  lower  part  of  the  abdomen  or  behind 
the  symphysis  pubis.  It  is  often  of  a  burning  or  smarting  character, 
and  may  extend  along  the  urethra  to  the  meatus.  Changes  in  the 
character  of  the  urine  are  always  present.  The  old  idea  that  cystitis 
was  always  associated  with  ammoniacal  urine  is  an  error.  The  reaction 
depends  upon  the  kind  of  infection  present,  and  we  may  have  a  severe 
cystitis  with  a  constantly  acid  urine,  as  shown  under  Bacteriology. 

When  the  cystitis  is  due  to  a  urea-decomposing  microbe,  the  urine 
is  alkaline,  ammoniacal,  and  irritating,  and  contains  the  usual  triple 
phosphate  crystals.  More  or  less  pus  is  always  present.  It  may  vary 
from  microscopical  quantities  to  sufficient  to  produce  a  slight  turbidity 
of  the  urine,  or  to  fi-om  10  to  25  per  cent  by  bulk  upon  sedimentation. 
The  urine  contains  an  incrcascsd  amount  of  mucus.  IsTumerous  squa- 
mous and  transitional  epithelial  cells  from  the  bladder  mucosa  are  always 


794  ^  TEXT-BOOK  OF  GYNECOLOGY 

found  on  microscopic  examination,  and  a  few  blood  cells  are  com- 
mon. In  acute  cases,  a  drop  or  two  of  blood  is  often  squeezed  out 
at  the  end  of  urination  by  the  spasmodic  action  of  the  bladder.  In 
so-called  gangrenous  or  sloughing  cystitis,  shreds  of  mucous  membrane 
may  be  passed.  The  ordinary  case  of  cystitis  is  unattended  by  any 
material  elevation  of  the  temperature,  but  in  case  of  abscess  formation 
in  the  wall  of  the  bladder,  of  pericystitis,  or  of  extension  of  the  infec- 
tion to  the  kidneys,  fever  may  become  a  prominent  symptom.  The  only 
difference  between  acute  and  chronic  cystitis  is  simply  one  of  time,  as 
the  symptoms  and  causation  may  be  the  same  in  each.  The  acute  form 
frequently  passes  imperceptibly  into  the  chronic,  and  chronic  cases 
are  subject  to  repeated  acute  exacerbations.  Acute  cystitis  may  be  ex- 
pected to  subside  under  proper  care  in  from  a  few  days  to  two  or  three 
weeks,  while  the  chronic  form  may  persist  with  varying  intensity  for 
months  or  years.  The  great  danger  in  cystitis  is  the  extension  of  the 
infection  to  the  kidneys.  More  remote  is  the  possibility  of  perforation 
of  the  bladder  with  infection  of  the  peritoneum  or  the  formation  of 
pericystic  abscesses.  As  similar  symptoms  and  changes  in  the  character 
of  the  urine  may  occur  in  diseases  of  other  portions  of  the  urinary 
tract,  the  diagnosis  of  cystitis  must  rest  upon  a  demonstration  of  the 
lesions  of  the  vesical  mucosa  or  upon  establishing  the  fact  that  the 
pathologic  elements  found  in  the  urine  have  their  origin  within  the 
bladder.  These  facts  are  determined  by  palpation  of  the  bladder,  by 
the  use  of  the  cystoscope,  and  by  segregation  of  the  urines.  Upon 
bimanual  palpation,  the  bladder  will  be  found  to  be  sensitive  if  in- 
flamed; and  if  the  inflammation  has  been  of  long  duration,  the  in- 
creased thickness  of  the  walls  can  be  easily  felt.  By  the  use  of  the 
cystoscope,  either  the  Kelly  tube  or  the  electro-cystoscopes,  the  various 
alterations  already  described  under  Pathologic  Changes  may  be  easily 
recognised  and  an  absolute  diagnosis  made.  By  ureteral  catheterization 
or  the  use  of  the  urine  segregator,  the  condition  of  the  kidneys,  as 
separate  from  the  bladder,  may  be  determined,  but  the  danger  of 
infecting  a  healthy  kidney  with  the  ureteral  catheter  in  the  presence 
of  a  septic  bladder  should  always  be  remembered.  The  diagnosis  is  not 
complete  without  a  bacteriological  examination  to  determine  the  nature 
of  the  infection.  The  general  health  in  mild  cases  may  be  but  little 
affected,  but  in  severe  cases  the  prolonged,  almost  continuous  suffering 
often  greatly  reduces  the  patient. 

Treatment. — As  the  bladder  possesses  considerable  reparative  power 
provided  the  predisposing  factors  mentioned  under  Etiology  are  re- 
moved, each  case  of  cystitis  should  be  diligently  studied  in  order  to 
discover  and  abate,  if  possible,  all  such  factors  as  favour  infection  or 
diminish  the  resisting  power  of  the  bladder.  Attention  should  thus 
be  directed  to  infections  about  the  vagina,  vulva  and  urethra;  to  stric- 
tures of  the  urethra,  or  other  causes  of  obstruction  to  the  free  escape 
of  urine;  to  intrapelvic  infections  or  tumours  that  press  upon  or  dis- 
tort the  bladder;  to  intestinal  diseases  that  may  permit  direct  or  indirect 


THE   FEMALE    URINARY   APPARATUS  795 

infection  of  the  bladder;  to  septic  foci  in  the  kidneys  producing  de- 
scending infection;  to  abnormal,  irritating  conditions  of  the  urine, 
and  to  foreign  bodies  or  tumours  in  the  bladder,  etc.  Having  relieved 
these  conditions,  so  far  as  possible,  attention  may  be  directed  to  the 
bladder  itself.  In  acute  cases,  the  patient  should  be  confined  to  bed. 
An  abundance  of  water  should  be  given  to  dilute  the  urine,  and  potas- 
sium carbonate,  citrate,  or  acetate,  to  reduce  its  acidity.  The  food 
should  be  very  light  and  mostly  of  a  liquid  character.  Hot  applica- 
tions to  the  hypogastric  region  and  vulva  afford  some  relief  to  the 
pain,  as  do  also  hot  sitz  baths,  and  hot  vaginal  douches.  The  pain 
and  burning  during  urination  may  be  ameliorated  by  having  the  patient 
urinate  in  the  sitz  bath  or  while  taking  a  vaginal  douche.  In  severe 
cases,  morphine  or  codeine  may  be  necessary  to  relieve  the  pain.  An 
excellent  combination  is  salol,  3  grains,  with  codeine,  ^  to  :^  of  a 
grain,  every  two  or  four  hours.  In  the  early  stages  of  very  severe  acute 
cases,  vesical  instrumentation  should  be  avoided;  but  after  the  most 
acute  stage  has  subsided,  or  in  milder  cases  from  the  beginning,  a  vesical 
douche  of  warm  3-per-cent  boric-acid  solution  gently  and  carefully 
given  will  be  found  of  great  service.  In  chronic  cases,  the  bladder 
should  be  cleansed  by  irrigation  daily  with  warm  boric-acid  solution,  or 
formalin  1  to  2,000  or  3,000  in  normal  salt  solution;  mercuric  bichlo- 
ride, 1  to  10,000  or  20,000,  or  silver  nitrate  1  to  1,000  or  2,000.  In 
all  cases,  the  interior  of  the  bladder  should  be  inspected,  and  where 
the  changes  are  found  to  be  circumscribed,  direct  application  of  a 
2-per-cent  to  3-per-cent  solution  of  silver  nitrate  should  be  made  to  the 
diseased  areas.  In  tuberculous  cystitis  with  ulceration,  the  ulcers  may 
be  curetted  and  from  2  to  4  drachms  (8  to  15  cubic  centi- 
metres) of  iodoform  emulsion  (10  per  cent)  allowed  to  remain  in  the 
bladder.  Internally,  such  remedies  may  be  given  as  have  been  found 
to  exert  an  inhibitory  action  on  the  growth  of  the  microbes  while 
being  eliminated  with  the  urine.  Of  these,  salol  and  urotropin  are  the 
best,  the  former  in  doses  of  5  grains  (0.3)  four  to  six  times  a  day,  and 
the  latter  of  from  7  to  10  grains  (0.5  to  0.7)  three  times  daily.  The  diet 
should  be  regulated,  and  all  irritating  articles  of  food  and  alcoholic 
drinks  interdicted. 

Should  the  above  means  fail  to  give  relief,  complete  rest  to  the 
bladder  should  be  secured  by  continuous  drainage  either  by  the  catheter 
a  denicvre  or  by  suprapubic  cystotomy. 

Hypersemia.- — Under  the  terms  hypersemia,  irritable  bladder,  neu- 
ralgia of  the  bladder,  etc.,  has  been  described  a  condition  which  is 
quite  common  in  women,  and  often  very  troublesome.  While  it  is 
possible  that  a  neuralgia  of  the  bladder  may  occur,  the  term  is  entirely 
unsuited  to  the  condition  at  present  under  discussion.  Of  the  other 
two  terms  mentioned,  hypersemia  seems  the  more  appropriate, 
although  it  is  quite  iujpossible  to  draw  a  sharp  distinguishing  line 
between  a  siniy)le  byperji'niin  and  a  mild  cystitis.  If  the  cases  of  so- 
called  "  irritable  bladder  "  are  examined  with  the  cystoscopc  and  the 


796  A   TEXT-BOOK  OF   GYNECOLOGY 

endoscope,  changes  quite  typical  of  a  mild  inflammation  will  be  ob- 
served in  a  large  majority  of  them.  These  changes  are  usually  quite 
circumscribed  in  outline.  They  may  be  limited  to  the  trigone  (trigo- 
nitis)  or  to  a  small  area  about  one  or  the  other  ureteral  opening. 
Most  frequently,  the  vesico-urethral  junction,  or  that  portion  which 
first  begins  to  fold  over  the  end  of  the  endoscope  as  it  is  withdrawn 
from  the  bladder,  will  be  found  involved.  These  areas  are  quite  red, 
often  swollen  or  slightly  oedematous,  very  sensitive  when  touched  with 
the  end  of  a  probe  or  applicator,  and,  at  times,,  they  bleed  easily,  par- 
ticularly the  above-mentioned  vesico-urethral  junction.  Many  of 
these  cases  are  undoubtedly  due  to  a  mild  infection,  and  the  question 
of  infection  is  the  only  distinguishing  point  between  a  simple  hyper- 
asmia  and  a  beginning  true  inflammation.  "Women  with  chronic  uter- 
ine displacements  are  common  sufferers  in  this  way,  and  Harris  has 
seen  a  number  of  cases  in  spinster  seamstresses  who  use  the  sewing 
machine  to  excess,  and  in  women  with  movable  kidneys.  A  neurotic 
element  is  often  strongly  marked,  and  many  times  the  vesical  symp- 
toms are  but  a  part  of  a  general  neurasthenia.  The  symptoms  are  a 
frequent  desire  to  urinate,  with  a  burning  or  smarting  sensation  ac- 
companying or  following  the  act.  The  discomfort  often  becomes  quite 
distressing.  Eemissions,  or  even  intermissions,  in  the  symptoms  are 
quite  common.  The  treatment  must  be  governed  by  the  etiologic  condi- 
tions present.  Uterine  complications  must  be  corrected;  and  concen- 
trated and  irritating  urine  must  be  diluted  and  modified  by  giving 
plenty  of  pure  water  and  such  diuretics  as  potassium  citrate,  with  triti- 
cuni  repens  or  stigmata  maidis.  Codeine  may  be  added  if  the  pain  is 
severe.  The  neurotic  element,  when  present,  must  be  duly  considered 
and  treated  with  proper  diet,  tonics^  exercise,  etc.  The  local  treatment 
consists  in  irrigations  with  warm  boric-acid  solution,  2  per  cent,  or  the 
direct  application  through  the  cystoscope  of  a  2-per-cent  to  4-per-cent 
solution  of  silver  nitrate  to  the  hypersemic  patches.  In  many  cases, 
particularly  in  those  associated  with  a  nervous  element,  dilatation  of 
the  urethra  is  followed  by  marked  improvement. 

Foreign  Bodies  in  the  Bladder. — By  the  term  foreign  bodies  is 
meant,  not  only  such  articles  as  are  wilfully  or  accidentally  introduced 
from  without,  but  also  such  as  originate  within  the  bladder.  Under 
the  latter  division  are  to  be  considered  vesical  calculi.  These,  as  pri- 
mary formations,  are  very  rare  in  the  female.  Most  primary  bladder 
stones  have  their  origin  in  small  calculi  that  descend  from  the  kidneys 
and,  failing  to  escape  from  the  bladder,  gradually  enlarge  by  the  fur- 
ther deposit  about  them  of  the  urine  salts.  The  rarity  of  such  stones 
in  the  female  is  due  to  the  short,  dilatable  urethra  which  readily  per- 
mits the  escape  of  any  concretion  that  may  enter  the  bladder  through 
the  ureters.  Whenever,  therefore,  a  primary  stone  is  found  in  the 
female  bladder,  it  is  usual  to  find  some  antecedent  condition  present 
which  interferes  with  the  prompt  and  complete  evacuation  of  the 
urine.    Among  such  conditions  may  be  mentioned  strictures  of  the  ure- 


THE   FEMALE   URINARY  APPARATUS  797 

tlira,  either  from  cicatricial  contraction  or  pressure  from  without;  tu- 
mours within  tlie  bladder  which  interrupt  the  escape  of  the  urine; 
pouching  of  the  bladder,  such  as  occurs  in  diverticula  and  cystocele; 
distortions  or  displacements  of  the  bladder  from  intrapelvic  tumours; 
adhesions  of  this  organ  to  neighbouring  parts,  which  interfere  with 
its  free  contraction,  etc.  In  the  presence  of  any  of  these  conditions, 
a  concretion  descending  from  the  kidney  may  remain  in  the  bladder 
and  develop  to  a  stone  of  considerable  dimensions.  As  such  stones 
are  identical  in  origin  and  structure  with  those  that  develop  within 
the  kidneys,  the  reader  is  referred  to  the  article  on  Eenal  Calculi  for 
their  etiology  and  composition.  By  far  the  large  majority  of  vesical 
calculi  in  the  female  are  not  of  the  so-called  primary  variety,  but 
develop  as  secondary  formations  about  foreign  bodies  that  have  been 
introduced  from  without.  Most  of  such  bodies  enter  the  bladder 
through  the  urethra,  but  other  routes  are  possible;  a  pessary,  for 
instance,  may  ulcerate  from  the  vagina  into  the  bladder;  ligatures 
placed  in  the  bladder  wall,  or  even  about  pedicles  in  the  pelvis,  may 
find  their  way  into  the  bladder;  particles  may  enter  from  the  ali- 
mentary canal  in  vesico-intestinal  fistula;  pieces  of  bone,  clothing, 
etc.,  may  be  carried  to  the  bladder  by  bullet  wounds,  etc.  As  already 
stated,  however,  the  urethra  is  the  most  common  route,  and  of  391 
cases  of  foreign  bodies  in  the  bladder  collected  by  Denuce,  258  were 
introduced  intentionally,  that  is,  out  of  morbid  curiosity  or  for  mas- 
turbating purposes.  Among  the  various  articles  thus  introduced, 
may  be  mentioned  hairpins,  glass-headed  pins,  beads,  pieces  of  lead 
pencils,  slate  pencils,  chewing  gum,  straws,  small  paraffin  candles, 
peas,  kernels  of  corn,  etc.  Foreign  bodies  may  likewise  find  their 
way  into  the  bladder  accidentally,  as  when  the  end  of  a  catheter  breaks 
oif  or  a  whole  glass  catheter  slips  in,  as  mentioned  by  Kelly,  or  a 
lithotrite  or  other  instrument  breaks  while  being  manipulated  within 
the  organ.  A  foreign  body  may  remain  in  the  bladder  a  long  time 
without  inducing  any  special  symptoms.  Thus,  Letulle  mentions  a 
case  in  which  a  penholder,  8  centimetres  long,  remained  in  the  blad- 
der three  months  without  producing  the  slightest  trouble,  and  Stein- 
itz,  one  where  a  broken-off  rubber  catheter  remained  seventeen  years 
without  giving  rise  to  any  considerable  difficulty.  Usually,  however, 
severe  symptoms  very  soon  arise.  Painful  contractions  of  the  bladder 
may  be  induced,  particularly  if  the  body  has  sharp  points,  and  per- 
foration of  the  organ  may  occur  with  the  development  of  a  fatal  peri- 
tonitis. Ordinarily,  the  symptoms  are  those  of  a  simple  cystitis ;  pain- 
ful, frequent  urination,  with  blood,  pus,  and  decomposition  of  the 
nn'7)f.  The  decomposition  of  the  urine  leads  to  the  deposition  of 
pliosphates  about  the  foreign  body  as  a  nucleus,  and  thus  are  devel- 
oped secondai-y  stones.  Wbile  the  pain  is  usually  more  severe  after 
emptying  the  bladder  or  following  exercise  or  jolting  of  the  body, 
and  wbile  the  amount  of  blood  present  in  the  urine  is  usually  more 
pronounced  than  in  ordinary  cases  of  cystitis,  still  the  symptoms  are 


798  ^  TEXT-BOOK  OF   GYNECOLOGY 

not  absolutely  characteristic  of  the  presence  of  a  foreign  body,  which 
fact  must  be  demonstrated  by  bimanual  palpation,  the  introduction 
of  the  sound,  or  inspection  through  the  cystoscope. 

The  ireatment  consists  in  the  removal  of  the  foreign  body,  whatever 
it  may  be.  A  primary  stone,  if  not  too  large,  may  be  removed  through 
the  dilated  urethra,  or  it  may  be  crushed  with  the  lithotrite  and 
washed  out  with  the  evacuator.  Much  ingenuity  must  often  be  dis- 
played in  the  removal  of  irregular  bodies  or  those  with  sharp  points. 
Much,  however,  may  be  done  through  the  dilated  urethra  with  the 
cystoscope  and  forceps,  while  the  patient  is  in  the  knee-chest  position 
and  the  bladder  distended  with  air.  In  dilating  the  urethra,  the  ex- 
ternal meatus  should  be  incised  laterally  and  in  the  middle  line,  and 
the  dilatation,  which  should  be  made  slowly  with  smooth  dilators, 
should  not  exceed  18  to  20  millimetres,  owing  to  the  danger  of  pro- 
ducing permanent  incontinence.  The  incisions  of  the  meatus  should 
subsequently  be  sutured.  When  the  body  can  not  be  removed  through 
the  dilated  urethra,  it  will  be  necessary  to  incise  the  bladder  either 
from  the  vagina  or  above  the  pubis.  The  suprapubic  route  is  usually 
to  be  preferred,  as  it  affords  easy  access  to  the  bladder  and  there  is 
no  danger  of  injuring  the  ureters  or  of  leaving  a  permanent  vesico- 
vaginal fistula.  By  distending  the  bladder  with  air,  the  peritoneal 
fold  is  well  raised  up  and  the  organ  may  be  opened  without  difficulty. 
The  incision  in  the  bladder  should  be  closed  with  catgut  stitches 
which  should  not  enter  the  vesical  cavity,  and  a  catheter  a  demeure 
introduced. 

Tumours  of  the  Bladder. — As  both  the  entoderm  and  the  meso- 
derm enter  into  the  formation  of  the  bladder,  nearly  all  varieties  of 
tumours  have  been  found  taking  origin  from  its  walls.  The  benign, 
mature  connective-tissue  tumours,  fibromata,  myomata,  and  lipomata, 
are  very  rare,  and  but  few  well-marked  specimens  have  been  recorded. 
They  have  their  origin  in  the  submucous  and  muscular  layers. 

The  malignant  embryonal  connective-tissue  tumours,  myxomata 
and  sarcomata,  although  more  common  than  the  benign  growths,  are 
still  to  be  classed  with  the  rarer  forms.  Of  the  epithelial  growths, 
the  carcinomata  are  much  the  more  frequent,  only  a  few  adenomata 
having  been  observed.  By  far  the  most  common  tumour  found  in  the 
bladder  is  the  so-called  papilloma  or  villous  growth. 

The  typical  villous  growth  is  made  up  of  a  number  of  delicate, 
slender  prolongations  which  subdivide  or  branch  similarly  to  an  ordi- 
nary shrub.  Each  little  prolongation  is  composed  of  a  central  blood- 
vessel loop,  surrounded  by  a  variable  amount  of  loose  connective  tissue, 
and  the  whole  covered  by  several  layers  of  epithelial  cells  of  the  vesicle 
type.  While  this  is  the  general  character  of  a  villous  growth,  varia- 
tions may  exist  in  the  length  and  size  of  the  prolongations,  number 
of  branches,  extent  of  attachment  at  the  base,  amount  of  connective 
tissue  present,  number  of  layers  of  epithelial  cells  on  the  surface,  etc. 
In  size,  they  may  vary  from  a  few  millimetres  in  height  and  circum- 


THE   FEMALE   URINARY   APPARATUS  799 

ference  to  several  centimetres.  Much  confusion  exists  in  the  litera- 
ture from  an  attempt  to  name  and  classify  the  papillomata. 

A  papilloma  may  exist  for  years  without  leading  to  the  destruc- 
tion of  tissue  or  the  patient;  it  may  be  removed  without  displaying 
the  slightest  tendency  to  recur,  thus  exhibiting  every  evidence  of  a 
benign  growth.  On  the  other  hand,  infiltration  and  destruction  of  the 
bladder  walls  may  result,  metastases  may  form,  and  rapid  recurrence 
after  removal,  and  death  within  a  short  time,  may  take  place,  thus 
exhibiting  every  evidence  of  great  malignancy.  The  papillomata 
may,  therefore,  be  classified  as  simple,  or  benign,  and  carcinomatous, 
or  malignant.  The  benign  growths  are  usually  pedvmculated,  with 
narrow  bases  and  without  infiltration.  The  malignant  are  more  ses- 
sile, with  broad  bases  and  infiltration  of  the  bladder  walls.  Typical 
exemplars  of  these  two  varieties  would  perhaps  be  easily  recognised, 
but  unfortunately  many  atypical  eases  are  found.  Cases  which  show 
no  infiltration  macroscopically,  may  show,  upon  microscopic  examina- 
tion of  serial  sections  through  the  base,  beginning  epithelial  inclusions 
and  prolongations  from  the  surface  layers.  These  cases,  after  re- 
moval, show  a  tendency  to  recur  as  typical  infiltrating  carcinomata. 
The  occurrence  of  such  cases  makes  it  impossible  always  to  determine, 
from  gross  appearance  alone,  whether  a  papilloma  is  benign  or  malig- 
nant. It  is,  therefore,  safer  to  look  upon  them  all  with  suspicion  and 
to  treat  them  as  if  they  were  malignant.  Tumours  of  the  bladder 
may  appear  at  any  time  of  life  from  infancy  to  old  age.  The  large 
majority  of  tumours  in  early  life  are  malignant.  Steinmetz 
{Deutsche  Zeitschrift  fur  Chirurgie,  Bd.  xxxix,  s.  313)  collected  33  cases 
in  childhood.  There  were  14  sarcomata;  13  myxomata;  1  fibromy- 
oma;  1  cystofibroma;  1  rhabdomyoma;  and  2  of  a  nature  not  stated. 
The  clinical  history  of  the  myxomata  differed  in  no  way  from  that 
of  the  sarcomata.  Concerning  the  age,  there  were  33  between  one  and 
five  years,  and  only  6  from  five  to  thirteen  years.  During  adolescence 
and  early  adult  life,  tumours  of  the  bladder  are  very  rare ;  after  thirty 
they  again  increase  in  frequency,  and  are  most  common  from  forty  to 
sixty. 

Symptomatology  and  Diagnosis. — In  adults,  the  first  symptom  is 
usually  hematuria.  This  is  of  the  so-called  spontaneous  variety; 
appearing  and  disappearing  without  apparent  cause,  and  usually  unin- 
fluenced by  exercise  or  exertion.  It  may  last  but  a  short  time  or  per- 
sist for  months  or  years,  and  may  be  slight  or  quite  severe.  For  a 
time,  there  may  be  no  subjective  symptoms  present;  sooner  or  later, 
however,  increased  frequency  of  urination  and  pain  are  noted.  These 
are  more  marked  and  appear  earlier  when  the  growth  occupies  the 
base  of  the  bladder  or  the  region  near  the  internal  orifice  of  the 
urethra.  A  peduneulatofl  growth  in  this  region  may  enter  the  urethra 
and  make  its  appearance  at  the  meatus  urinarius.  This  has  been 
particularly  noted  in  children,  and  has  frequently  been  the  first  symp- 
tom directing  attention  to  the  bladder.     When  the  bladder  becomes 


800  ^  TEXT-BOOK  OP   GYNECOLOGY 

infected,  as  it  is  particularly  prone  to  do  in  malignant  cases,  the 
sjanptoms  are  those  of  an  ordinar}^  cj^stitis.  In  about  25  per  cent  of 
malignant  cases,  the  earlier  symptoms  are  those  of  a  simple  cystitis. 
It  is  impossible  to  distinguish  between  a  benign  and  a  malignant 
growth  by  the  symptoms  in  the  early  stage,  but  later,  the  cachexia, 
loss  of  flesh,  failure  of  general  health,  etc.,  stamp  the  case  as  ma- 
lignant. 

Direct  inspection  of  the  interior  of  the  bladder  through  the  cysto- 
scope  is  the  only  means  of  making  a  positive  early  diagnosis  of  blad- 
der tumour.  By  the  use  of  this  instrument,  the  extent  and  the  gen- 
eral physical  characteristics  of  the  growth  may  be  observed.  An  infil- 
trating, ulcerating  growth  is  almost  certainly  malignant,  but  in  the 
case  of  a  papilloma  it  will  be  difficult  to  decide,  and  it  is  better  to 
await  the  findings  of  the  microscope  before  expressing  a  positive 
opinion.  The  duration  of  a  benign  growth  is  often  one  of  years,  but 
a  malignant  tumour  is  usually  fatal  in  from  one  to  three  years. 

Treatment. — All  tumours  of  the  bladder  should  be  removed  as  soon 
as  possible.  Pedunculated  growths  may  often  be  removed  through 
the  dilated  urethra  Avith  the  snare  or  galvano-caustic  loop,  but  in  the 
majority  of  cases  the  suprapubic  route  will  be  found  the  most  satis- 
factory, as  it  permits  free  access  to  all  parts  of  the  bladder  and  a 
more  thorough  removal  of  the  growth.  Even  in  cases  that  appear 
benign,  it  is  safer  to  remove  the  base  freely,  as  if  it  were  malignant. 
In  infiltrating  malignant  growths  a  resection  of  the  bladder  walls 
should  be  made.  This  is  not  so  difficult  when  the  mass  occupies  the 
fundus,  but  when  the  base  is  involved,  or  the  region  about  the  ureters, 
it  becomes  a  very  serious  and  difficult  operation.  The  ureters  must 
be  transplanted  higher  up  in  the  posterior  wall  or  fundus.  When  the 
organ  is  extensively  involved,  it  may  be  necessary  to  remove  it  com- 
pletely. This  has  been  successfully  done,  and  the  case  of  Pawlik 
may  be  taken  as  a  model,  although  the  details  of  each  operation  will 
have  to  be  worked  out  by  the  operator  and  modified  to  suit  the  indi- 
vidual ease.  Pawlik  turned  the  ureters  into  the  vagina  as  a  prelim- 
inary operation.  He  then  removed  the  bladder  working  from  above 
and  below,  but  preserved  the  urethra  which  he  likewise  turned  into 
the  vagina.  The  vaginal  opening  was  subsequently  closed  and  this 
organ  made  to  supply  the  place  of  a  bladder.  The  ultimate  result  was 
very  gratifying. 

Urethral  Caruncle. — With  the  exception  of  gonorrhosal  urethritis, 
diseases  of  the  female  urethra  are  rare.  The  conditions  most  com- 
monly met  with  are  tumours,  diverticula,  strictures,  prolapse,  the  pres- 
ence of  foreign  bodies,  and  dilatation.  Of  the  tumours,  the  most  com- 
mon is  the  urethral  caruncle.  This  usually  presents  itself  as  a  small 
red  mass  projecting  from  the  orifice  of  the  urethra  and  attached  by 
a  narrow  pedicle  to  the  mucosa  within  the  meatus.  It  is  often  some- 
what flattened  laterally  owing  to  pressure  between  the  labia.  It  is 
composed  of  connective  tissue  abundantly  supplied  with  blood  vessels 


THE   FEMALE   URINARY   APPARATUS  801 

and  covered  with  several  layers  of  flattened  epithelial  cells.  These 
little  growths  are  usually  exquisitely  sensitive.  Urination  is  so  pain- 
ful that  the  act  is  delayed  as  long  as  ^^ossible,  and,  in  the  married, 
marital  relations  are  often  impossible  owing  to  the  acute  pain  pro- 
duced by  the  gentlest  touch.  They  may  occur  at  any  age,  but  are  more 
common  later  in  life.  In  the  presence  of  such  symptoms  the  diagno- 
sis is  easily  made  by  inspection. 

Treatment  consists  in  removal.  This  may  be  done  under  local 
anaesthesia  by  the  application  for  a  few  minutes  of  a  10-per-cent 
sohition  of  cocaine.  The  little  mass  should  be  drawn  out  and  the 
pedicle  divided  close  up  to  the  base.  Should  the  base  be  quite  broad, 
the  wound  may  be  closed  by  stitches. 

Carcinoma  of  the  urethra,  as  either  a  primary  or  a  secondary  affec- 
tion, is  not  common.  Ehrendorfer  (Archiv  fur  Gynakologie,  Bd.  Iviii, 
s.  463)  was  able  to  collect  27  cases  from  the  literature  including  one 
of  his  own.  These  cases  presented  three  forms:  1.  Warty,  papillo- 
matous excrescences,  developing  from  the  mucosa  and  projecting  from 
the  urethra;  2.  Thick,  nodular,  infiltrating  masses  in  the  periurethral 
tissues,  involving  more  or  less  of  the  circumference  of  the  urethra  and 
usually  located  toward  the  external  end,  and  3.  Ulcerated  surfaces 
with  thickened,  irregular  and  infiltrated  edges.  These  may  begin  at 
any  point  along  the  canal  including  the  meatus.  Enlargement  of  the 
inguinal  lymph  glands  was  recognised  and  mentioned  in  only  about 
one  third  of  the  cases.  As  is  usual  with  carcinoma,  the  majority  of 
the  cases  occurred  late  in  life. 

The  symptoms  first  complained  of,  are  usually  a  sense  of  itching 
and  irritation  about  the  meatus  or  vulva,  due  to  the  irritating,  acrid 
discharge  commonly  present,  and  pain  or  smarting  on  urinating.  The 
presence  of  these  symptoms  should  always  lead  to  an  examination, 
when,  on  inspection,  with  the  aid  of  the  endoscope  if  necessary,  and 
palpation,  one  of  the  above-described  conditions,  should  it  exist,  will 
be  recognised  and  a  diagnosis  made. 

The  treatment  is  early  and  thorough  removal.  The  anterior  por- 
tion of  the  urethra  may  be  removed  and  continence  of  urine  remain. 
Should  it  be  necessary  to  remove  the  entire  urethra,  the  bladder  may 
be  closed  below  and  a  suprapubic  opening  made  after  the  method  of 
Witzel. 

Sarcoma  of  the  urethra  has  been  noted,  but  the  clinical  history  and 
treatment  do  not  differ  from  that  of  carcinoma  (see  Neoplasms  of  the 
p]xternal  Organs,  Chapter  XIX).  Of  the  benign  tumours,  a  few 
cases  of  fihroma  have  been  described  occurring  for  the  most  part  in 
little  girls.  They  presented  as  small  polypoid  masses  protruding  from 
the  urethra  and  attached  by  a  narrow  pedicle.  Their  removal  is  a 
simple  matter. 

Diverticula  usually  extend  Froin  llic  posterior  wall  of  the  urethra 
toward  tbe  vagina.  '■J''hey  may  vary  in  siz(?  from  that  of  a  pea  to  that 
of  a  cavity  holding  several  cubic  centimetres.  According  to  Eoush, 
53 


802  A  TEXT-BOOK  OF   GYNECOLOGY 

they  originate  from  the  rupture  of  retention  cysts,  blood  cysts,  or 
periurethral  abscesses  into  the  urethra.  The  distended  pocket  pro- 
duces a  protrusion,  or  bulging,  of  the  anterior  wall  of  the  vagina, 
easily  seen  on  separating  the  labia.  Upon  pressure,  the  enlargement 
diminishes  in  size  and,  at  the  same  time,  pus  or  pus  and  urine  escape 
from  the  urethra.  An  examination  with  the  endoscope  will  reveal  a 
small  opening  in  the  posterior  wall  of  the  urethra  from  which  the  pus 
escapes,  and  through  which  a  probe  may  be  passed  into  the  cavity. 
Owing  to  the  decomposition  of  the  urine,  which  takes  place  in  the 
cavity,  a  calculus  may  form  therein.  Most  of  these  cases  give  a  his- 
tory of  long-continued  vesical  irritation  with  frequent,  painful  urina- 
tion, etc. 

The  treatment  consists  in  opening  the  sac  freely  from  the  vagina, 
curetting  the  walls,  or  painting  with  tincture  of  iodine  and  packing 
with  gauze.  Should  this  not  be  successful,  an  attempt  may  be  made 
to  dissect  out  the  sac. 

Strictures  of  the  female  urethra  are  quite  rare.  They  are  due  to 
cicatricial  contraction  following  injury  the  result  of  external  violence 
or  lacerations  during  labour,  and  they  occasionally  follow  a  virulent 
gonorrhoeal  infection  or  the  healing  of  a  urethral  chancre.  They 
may  be  easily  recognised  with  the  bougie  a  houle  and  should  be  treated 
by  gradual  dilatation  or  division  followed  by  dilatation. 

Prolapse  of  the  iirethral  mucosa  may  follow  a  difficult  labour  or 
may  occur  in  poorly  nourished  young  girls  following  straining,  cough- 
ing, etc.  In  a  severe  urethritis  the  mucosa  may  become  so  swollen 
as  to  protrude  considerably.  In  some  cases  it  is  impossible  to  assign 
a  direct  cause  for  the  prolapse.  The  prolapsed  mucosa  presents  a 
dark  red  or  bluish  mass,  which  is  sensitive  and  bleeds  easily,  and  in 
the  centre  of  which  may  be  found  an  opening  leading  into  the  urethra 
(Fig.  86,  Displacements  of  the  Vagina).  If  allowed  to  remain  long 
protruded,  the  mass  may  become  so  constricted  as  to  produce 
sloughing. 

Treatment. — An  attempt  should  be  made  to  reduce  the  mass  by 
gentle  pressure.  Permanent  reduction  has  followed  the  application 
of  an  ice  bag  to  the  parts  with  the  patient  in  the  recumbent  position. 
Should  these  means  fail  or  should  sloughing  threaten,  the  mass  may 
be  removed  with  the  knife  or  scissors,  the  edges  being  carefully 
stitched  to  prevent  hemorrhage  and  retraction  as  described  under  Dis- 
placements of  the  Vagina. 

Foreign  bodies  in  the  urethra  arc  small  calculi  that  have  lodged 
in  attempting  to  pass  from  the  bladder,  or  that  develop  in  a  dilated  or 
pouched  urethra;  or  they  are  small  bodies  introduced  from  without 
through  the  meatus.  They  give  rise  to  painful  and  difficult  urina- 
tion, and  can  be  felt  by  the  finger  pressing  along  the  urethra  through 
the  anterior  wall  of  the  vagina  or  by  introducing  a  probe  or  catheter 
into  the  canal.  Calculi  are  usually  of  the  phosphatic  variety.  Re- 
moval may  be  effected  through  the  dilated  urethra  by  means   of  a 


THE  FEMALE   URINARY  APPARATUS  803 

small  forceps  or  a  wire  loop.  When  lodged  in  a  pocket,  it  may  be 
necessary  to  incise  the  pouch  from  the  vagina  in  order  to  reach  the 
stone. 

Dilatation  of  the  urethra  may  occur  from  the  introduction  of  large 
bodies  from  without  or  the  expulsion  of  calculi  or  tumours  from 
within.  Coitus  per  urethram  in  women  with  atresia  of  the  vagina,  and 
the  introduction  of  large  foreign  bodies  for  masturbating  purposes, 
have  given  rise  to  extreme  dilatation  with  eversion  and  gaping  of  the 
urethral  orifice.  Severe  laceration  of  the  urethra  has  been  produced 
by  attempts  at  coitus.  Fritsch  is,  therefore,  of  the  opinion  that  at 
least  a  congenital  disposition  to  dilate  is  present  in  those  cases  of 
extreme  dilatation  that  have  occurred  without  the  production  of 
symptoms.  More  or  less  incontinence  of  urine  is  the  usual  result  in 
these  cases.  Upon  the  slightest  straining,  such  as  coughing,  sneezing, 
or  making  a  sudden  misstep,  urine  escapes  and  soils  the  patient  so 
that  the  condition  becomes  very  annoying. 

Treatment. — In  slight  degrees  of  dilatation,  the  application  of  a 
lO-per-cent  solution  of  silver  nitrate  to  the  interior  of  the  iirethra 
has  been  followed  by  benefit.  The  use  of  astringent  vaginal  douches 
and  tampons  may  be  tried,  or  a  pessary  so  constructed  as  to  press  on 
the  urethra  may  be  worn.  When  the  dilatation  is  marked,  these 
means  will  seldom  be  found  sufficient.  It  will  then  be  necessary  to 
resort  to  operative  measures.  Several  procedures  have  been  employed, 
the  most  reliable  of  which  are:  1.  The  removal  by  an  elliptical  inci- 
sion of  a  portion  of  the  anterior  vaginal  wall,  extending  down  to,  or 
even  including,  the  wall  of  the  urethra,  with  closure  of  the  space  by 
transverse  stitches.  2.  Freeing  the  distal  end  of  the  urethra  by  dis- 
section and  carrying  it  forward  or  upward  toward  the  clitoris  where  it 
is  brought  to  the  surface  through  a  new  opening  in  the  vestibule.  3. 
Gersuny's  operation  of  dissecting  the  urethra  free  throughout  its 
entire  length  and  twisting  it  upon  its  axis  from  180  to  360  degrees. 
It  is  then  stitched  in  this  position.  4.  Fritseh's  operation,  which 
consists  in  removing  an  elliptical  piece  from  the  dorsal  surface  of  the 
urethra  at  its  junction  with  the  bladder  through  a  transverse  incision 
between  the  urethra  and  the  arch  of  the  pubis.  The  urethra  is  closed 
with  catgut  stitches,  the  wound  packed,  and  the  bladder  drained  by  a 
self-retaining  catheter. 

The  selection  of  the  method  of  operating  will  depend  somewhat 
upon  the  severity  of  the  case.  Gersuny's  and  Fritseh's  operations  are 
suitable  for  the  more  marked  cases. 

The  urachus  is  a  cordlike  remnant  of  foetal  structure  extending 
from  (lie  I'undus  of  the  bladder  to  the  umbilicus.  It  is  a  portion  of 
the  allantoic  vesicle,  from  which  were  derived  the  urethra  and  bladder. 

This  rudimentary  canal  consists  of  three  layers:  (a)  an  inner  epi- 
thelial layer;  (h)  a  middle  basement  membrane,  and  (c)  an  outer 
fibrous  layer.  The  epithelial  layer  consists  of  a  variety  of  cells,  cor- 
responding in  form  and  size  to  those  found  in  various  parts  of  the 


804 


A  TEXT-BOOK  OF   GYNECOLOGY 


urinary  apparatus.  They  are  either  ovoid  or  polygonal,  and  are  gen- 
erally nucleated.  The  intermediate  layer  of  basement  membrane  is 
described  by  Luschka  as  being  structureless,  delicate  and  transparent. 
The  outer,  or  fibrous,  layer,  while  attached  to  the  outer  side  of  the 
basement  membrane,  is  distinctly  separated  from  the  surrounding 
cellular  tissue.  It  will  be  seen,  therefore,  that  while  this  structure 
exists  as  a  blind,  and  ordinarily  functionless,  canal,  it  possesses  all 
the  histological  elements,  to  render  it  a  highway  of  communication. 
Luschka  declares  that,  in  the  majority  of  male  subjects,  this  canal  is 
found  to  be  partially  opened,  and  goes  to  the  extent  of  stating  that 
it  possesses  a  mucous  membrane.  If  this  is  true,  as  it  may  be  in 
certain  instances,  the  necessity  for  its  patulousness  becomes  apparent. 
Vesico-umbilical  fistula  is  occasionally  encountered,  and  is  the 
result  of  the  failure  of  the  urachus  to  become  closed  at  both  its  vesical 

and  umbilical  extremities. 
It  is  generally  observed  as 
a  congenital  condition,  al- 
though it  has  been  found 
in  patients  of  forty  and 
even  sixty-six  years  of 
age.  When  urine  escapes 
from  the  navel,  this  con- 
dition may  be  premised. 
A  flexible  sound  can  gen- 
erally be  passed  without 
difficulty  from  the  navel 
orifice  into  the  bladder. 
The  bladder  in  such  cases 
can  be  catheterized  by  this 
route.  "W^iile  in  the  ma- 
jority of  cases  this  condi- 
tion is  congenital,  there 
are  instances  on  record  in 
which  an  opening  has 
been  forced  through  the 
urachus,  by  retention  of 
urine.  Atresia  of  the  ure- 
thra, due  to  gonorrhoea, 
prostatic  enlargement, 
and  phimosis,  has  been 
recorded  as  a  direct  ex- 
citing cause  of  vesico-um- 
bilical fistula.  The  treat- 
ment consists  in  removing  the  urachus  by  abdominal  section.  A  median 
incision  should  be  made  from  the  umbilicus  to  near  the  pubis;  the  canal 
should  then  be  dissected  out  and  its  lower  extremity  ligated.  As  a  pre- 
caution against  the  extravasation  of  urine  into  the  peritoneal  cavity,  it 


Fig.  3-21. — "The  sac  extended  from  near  the  eusiform 
cartilage  to  the  pubes." — Eeed  (page  805). 


THE  FEMALE    URINARY   APPARATUS  805 

is  well  to  fix  the  pedicle  of  the  urachus  in  the  lower  angle  of  the  ahdomi- 
nal  incision.  Before  undertaking  the  operation,  it  is  well  to  observe  the 
admonition  of  Douglas,  by  making  sure  that  the  calibre  of  the  urethra 
is  sufficient  to  enable  the  urine  to  escape. 

Cyst  of  the  urachus  may  result  from  an  occlusion  of  both  the 
umbilical  and  the  vesical  ends  of  the  canal,  secretion  from  its  mucous 
surface,  as  described  by  Luschka,  presently  converting  it  into  a  reten- 
tion cyst.  The  fluid  in  these  cases  rarely,  if  ever,  possesses  any  uri- 
nary elements,  and  must,  consequently,  be  derived  from  the  wall  of  the 
sac.  In  a  case  under  Eeed's  observation,  the  sac  extended  from  near  the 
ensiform  cartilage  to  the  pubes  and  forced  the  viscera  from  their  normal 
positions  (Fig.  331).  The  cyst  was  enucleated  without  opening  the 
peritoneal  cavity.  Similar  cases  have  been  reported  by  Douglas  and 
Alban  Doran,  and,  previously,  by  Tait,  Wolf,  111,  Freer  and  others. 
The  condition  may  be,  and  generally  is,  mistaken  for  an  ovarian 
cyst.  The  facts,  however,  that  it  is  immovable,  that  it  occupies  a 
median  position,  and  that  it  has  generally  been  a  long  time  develop- 
ing, should  suggest  its  urachal  origin.  Cysts  of  minor  size  generally 
elude  detection  until  they  are  encountered  incidentally  in  the  course 
of  an  abdominal  operation  undertaken  for  another  purpose.  The 
treatment  of  these  tumours  is  by  abdominal  section.  The  sac  should 
be  carefully  enucleated.  If  ordinary  precaution  is  taken  in  this 
manipulation,  the  peritoneal  cavity  need  not  be  invaded — at  least  in 
the  majority  of  cases.  In  a  number  of  cases  on  record,  it  has  been 
possible  to  enucleate  these  sacs  without  discovering  a  pedicle,  thus 
showing  that  the  connection  between  the  urachus  and  the  bladder  had 
been  broken  up — probably  in  the  course  of  evolution. 


CHAPTER   L 

THE    RECTUM 

Malformations — Examination — Displacements — General  etiology  of  rectal  disease 
— Relation  of  mtrapelvic  disease  to  disease  of  the  rectum  in  women. 

The  rectum  is  the  lower  segment  of  the  alimentary  canal  and 
extends  from  the  sigmoid  flexure  to  the  anus.  It  passes  from  opposite 
the  left  sacro-iliac  s3"nchrondrosis,  from  left  to  right,  to  near  the  middle 
of  the  sacrum,  whence  it  descends  in  the  median  line  to  the  anus.  It  is 
narrower  at  its  intestinal  than  at  its  anal  end.  Its  upper  portion  is 
covered  by  peritoneum,  which  constitutes  the  mesorectum;  its  muscular 
layers  are  two  in  number,  one  of  longitudinal  fibres,  beneath  which  are 
circular  fibres  comprising  the  sphincter  ani  internus.  The  rectum  is 
lined  with  a  mucous  membrane  which  is  united  with  the  muscular  layer 
by  connective  tissue  and  is  covered  with  columnar  epithelium,  being 
raised  into  crescentic  longitudinal  folds  called  the  columns  of  Morgagni, 
or  the  transverse  rectal  folds.  The  rectum  is  held  in  position  by  the 
mesorectum,  by  its  connections  with  the  circumrectal  tissues  in  its 
lower  third,  and  by  the  muscular  apparatus  embraced  in  the  two  layers 
of  the  pelvic  floor.     (See  The  Pelvic  Floor.) 

Malformations  of  the  rectum  and  anus  are  of  more  frequent  occur- 
rence in  male  than  in  female  children.  They  may,  according  to  Boden- 
hamer  (Neiv  Yorl-  Medical  Jovrrial,  May  35,  1889),  consist  of  (1)  a 
preternatural  narrowing  or  stenosis  of  the  anus  at  its  margin,  occasion- 
ally extending  a  short  distance  above  this  point;  (2)  complete  occlusion, 
of  the  anal  aperture  by  a  simple  membrane  or  by  the  common  integu- 
ment or  a  substance  analogous  to  it,  more  or  less  thick  and  hard;  (3) 
absence  of  the  anus  with  partial  deficiency  of  the  rectum,  which  ter- 
minates in  a  cul-de-sac  at  a  greater  or  less  distance  above  its  natural 
outlet;  (4)  a  normal  anus  associated  with  a  rectum  which,  at  variable 
distances  above,  is  either  deficient,  obliterated,  or  completely  obstructed 
by  a  membranous  septum;  (5)  a  rectum  terminating  externally  by  an 
abnormal  anus  located  in  some  unnatural  situation,  e.  g.,  the  sacral 
region,  the  perineum,  within  the  fourchette,  etc.  (see  Malformations  of 
the  Vulva),  the  abnormal  anus  thus  formed  being  deficient  in  func- 
tional power;  (6)  the  rectum  opening  into  the  bladder,  urethra  or 
vagina,  or  into  a  cloaca  in  the  perineum  with  the  urethra  and  the 
vagina;  (7)  a  rectum  normal  in  itself,  but  having  the  ureters,  the  vagina 
or  the  uterus  opening  abnormally  into  it;  (8)  complete  absence  of  the 
806 


THE  RECTUM  807 

rectum;  (9)  absence  of  both  the  rectum  and  colon  and  the  termination 
externally  of  some  other  portion  of  the  intestinal  canal  in  an  abnormal 
anus  in  some  extraordinary  part  of  the  body;  e.  g.,  the  umbilicus,  the 
left  iliac  fossa,  the  lower  part  of  the  abdomen  just  above  the  symphysis 
pubis,  below  the  scapula,  and  at  the  side  of  the  face,  for  it  has  been 
known  to  occupy  each  of  these  situations.  In  the  last-named  class  no 
normal  anus  ever  exists. 

The  prognosis  of  congenital  malformations  of  the  rectum  and  anus 
must  depend  largely  upon  the  character  of  the  malformation.  As  indi- 
cated in  the  preceding  paragraph,  these  malformations  vary  greatly.  It 
may  be  stated  as  a  rule,  however,  that  classes  (3)  and  (4)  are  of  rela- 
tively more  frequent  occurrence  than  the  others,  and  to  them  alone 
special  attention  will  be  given  in  this  chapter.  Whenever  the  malfor- 
mation is  of  such  character  as  to  obstruct  the  faecal  current,  the  condi- 
tion, if  not  overcome,  must  necessarily  result  in  death.  Without  refer- 
ence to  the  classification  of  cases,  out  of  345  patients  upon  whom  opera- 
tions had  been  performed,  160  recovered.  This  is  an  encouraging 
outlook,  particularly  when  the  desperate  character  of  the  cases  is  taken 
into  consideration,  and  when  it  is  remembered  that  many  of  the  cases 
embraced  in  this  table,  compiled  by  Bodenhamer,  were  operated  on  in 
the  preantiseptic  era.  Matas  {Transactions  of  the  American  Surgical 
Society,  1897),  in  a  valuable  contribution  on  Anorectal  Imperf oration, 
the  condition  designated  in  Bodenhamer's  third  and  fourth  classes,  em- 
phasizes the  fact  that,  in  the  development  of  this  condition,  the  rectum 
and  anus  have  simply  failed  to  meet  in  the  process  of  development. 
There  is  defective  development  of  either  the  proctodseum  or  enteron, 
leaving  the  rectal  pouch  of  the  colon  at  a  distance  varying  from  a  few 
millimetres  to  5  or  more  centimetres  from  the  perineum;  or  the  enteron 
may  be  entirely  absent  and  remain  out  of  the  pelvis  altogether. 

The  symftoms  of  imperforate  anus  consist  in  an  absence  of  the 
faecal  discharge  and  in  restlessness,  which  may  develop  into  spasms  of 
the  infant.  Abdominal  distention  speedily  ensues,  but  before  this 
occurs,  the  vigilance  of  the  nurse  will  have  detected  the  true  condition 
of  affairs.  The  diagnosis  of  the  condition  within  the  pelvis,  however, 
is  far  more  difficult,  if,  indeed,  it  is  not  impossible.  Probes,  sounds, 
or  guides,  passed  into  the  vagina  or  bladder,  and  the  use  of  the  aspirat- 
ing needle,  are  equally  fallacious. 

Treatment  consists  in  establishing  the  faecal  current.  This  may 
be  done,  by  establishing  an  anus  either  at  its  normal  situation,  or  in 
the  inguinal  region.  Matas  gives  it  as  an  axiom,  that  it  is  the  duty 
of  the  surgeon  to  presume  that  there  is  a  rectal  pouch  in  the  pelvis  and, 
if  possible,  to  make  an  anal  connection  with.it.  This  presumption  is 
based  upon  tlie  fact  made  apparent  by  Bodenhamer's  table,  namely,  that 
the  rectum  and  colon  were  totally  absent  in  only  41  out  of  465  cases. 
AVTiatever  is  done  in  these  cases  should  be  done  early.  Delay  based 
upon  the  theory  that  infants  can  not  resist  traumatism,  and  that  in 
these  cases  it  is  better  to  give  tliem  time  in  which  to  acquire  strength. 


808 


A  TEXT-BOOK  OF  GYNECOLOGY 


is  a  fatal  and  tragic  fallacy.  Delay  under  such  circumstances  means, 
not  only  the  wasting  of  the  child's  strength,  but  the  development  of 
peritonitis  followed  by  stercorfemia  and  death  from  exhaustion.  The 
object  of  an  operation  should  be  to  establish,  if  possible,  an  intestinal 
outlet  in  its  normal  situation  in  the  perineal  sacral  region  with 
sphincteric  control.  This  should  be  accomplished  by  means  of  procto- 
plasty— i.  e.,  by  dissection  down  upon  the  rectal  pouch  and  its  fixation 
to  the  cutaneous  margin.  In  making  this  section,  it  may  be  necessary 
to  carry  the  incision  well  back  to  the  coccyx  or  even  up  into  the  sacrum. 
If,  after  making  this  incision,  it  is  found  to  be  impracticable  to  attach 
the  terminal  portion  of  the  colon  (rudimentary  rectum)  to  the  external 
wound,  it  is  justifiable  in  the  emergency  to  attach  the  small  bowel. 
Matas  states  that  a  median  or  lateral  or  exploratory  abdominal  section 
is  indicated  when,  after  the  intraperitoneal  exploration  through  a 
perineal  sacral  incision,  it  is  evident  that  the  terminal  cul-de-sac  of 
the  rectum  or  any  portion  of  the  colon  can  not  be  brought  down  to  the 
pelvic  outlet,  and  that  only  the  small  intestine  is  available  for  procto- 
plasty. The  aim  of  the  operator,  after  making  an  exploratory  abdom- 
inal incision,  according  to  ]\Iatas,  should  be  to  guide  the  colon,  the 

cfficum  or  the  most  available 
loop  of  the  ileum,  to  the  peri- 
neosacral  wound,  where  it  can 
be  drained  permanently  with 
greater  safety.  The  perineo- 
sacral  anus,  if  the  operation 
has  been  properly  performed, 
is  almost  certain  to  be  volun- 
tarily controlled  in  the  course 
of  time.  Keen  (Medical  Mir- 
ror) suggests  inguinal  colos- 
tomy as  the  operation  of  choice 
in  imperforate  rectum,  affirm- 
ing that  it  is  safer  to  life  and 
has  the  additional  advantage  of 
being  done  with  facility,  there 
being  no  groping  in  the  dark 
in  a  narrow  wound,  while  the 
time  consumed  is  much  short- 
er. In  this  suggestion.  Keen 
follows  in  the  footsteps  of 
Chassaignac,  Lannelongue  and 
others,  who,  however,  looked 
upon  the  inguinal  operation  as 
a  tentative  measure,  to  be  followed  later  by  a  perineal  operation  for 
the  establishment  of  an  anus  at  its  normal  situation. 

The  Examination  of  the  Rectum. — Noninstrumental  Proctoscopy.— 
The  essentials  of  this  method  are  a  patient,  an  assistant,  and  an  operator 


Fig.  322. — "  The  surgeon  is  to  close  liis  hands  aiui 
to  point  his  index  fingers." — Martin  (page  809). 


THE  RECTUM 


809 


having  at  least  one  finger  on  each  hand.  The  patient  is  to  be  put  into 
the  knee-chest  posture;  the  assistant  is  to  place  and  to  hold  the  patient; 
and  the  surgeon's  fingers  are  to  be  used  to  open  the  anus,  all  in  the 
following  manner,  to  wit: 

1.  The  patient  is  to  be   completely  anaesthetized  as  she  lies   on 
her  back,  and  then  turned  toward  the  assistant  and  into  the  Sims 
posture.     2.  The  assistant  is  to  station  himself  at  the  patient's  knees. 
In  his  left  hand  he  is  to  grasp 
the  patient's  feet.     He  is  to 
lean  himself  against  the  pa- 
tient's knees.     He  is  to  pass 
his  right  arm  under  the  pa- 
tient's hips.     Now  steadying 
the  feet  and  bearing  himself 
firmly    against    the    patient's 
knees,  with  his  right  arm  he  is 
to  lift  the  hips  and  pull  his 
subject  into  the  knee-shoulder 
posture. 

Here,  securely  held  in  the 
embrace  of  the  assistant,  the 
patient  is  to  be  balanced  on 
her  perpendicular  right  thigh, 
where,  throughout  the  whole 
time  of  the  surgeon's  manipu- 
lations, she  must  be  steadily 
held.  (A  Simplest  Proctos- 
copy, Martin,  Journal  of  the 
American  Medical  Association, 
August  27,  1898).  3.  The 
surgeon  is  to  close  his  hands 
and  to  point  his  index  fingers 

(Fig.  322).  The  wrists  are  to  be  crossed,  the  hands  placed  back  against 
back,  and  the  nails  of  the  index  fingers  placed  one  against  the  other 
(Fig.  323).  The  surgeon  is  to  lubricate  these  fingers  and  gently  insinu- 
ate them  through  the  anus  and  place  their  ends  beyond  the  borders  of 
the  levatores  ani.  This  accomplished,  the  anus  is  to  be  kneaded  and 
divulsed  in  the  direction  of  the  ischial  tuberosities,  by  the  surgeon 
forcibly  parting  his  fingers  as  is  shown  in  the  accompanying  illustration 
(Fig.  322).  Under  this  manipulation  the  rectum  becomes  atmospheric- 
ally inflated. 

Now,  provided  the  surgeon  lowers  his  head  to  the  level  of  his  fingers 
and  then  rises  again,  or  stoops,  or  moves  a  little  from  side  to  side,  he 
may  command  under  his  eye  a  view  of  the  atmospherically  inflated 
rectum  to  the  depth  of  6  or  8  inches  (15.24  or  20.32  centimetres), 
and,  in  some  instances,  he  may  behold  even  a  part  of  the  sigmoid  flexure. 
Tt  is  possible  for  the  operator  to  manipulate  his  patient  and  to  finish 


Fig.  323. — "  The  wrists  ai-e  to  be  crossed  .  .  .  and 
the  nails  of  the  index  fingers  placed  one  against 
the  other." — Martin. 


810 


A  TEXT-BOOK   OF  GYNECOLOGY 


his  inspection  within  two  and  a  half  or  three  minutes,  provided  the 
patient  is  in  a  state  of  complete  anesthesia. 

If  this  method  is  practised,  as  it  may  be  with  facility  by  the  gen- 
eral practitioner,  the  greater  number  of  rectal  diseases  may  be  instan- 
taneously diagnosticated.  But  at  diagnosis  the  achievement  of  the 
simplest  proctoscopy  ends,  for  the  reason  that  the  operator's  hands 
are  so  full  of  his  patient  he  can  do  nothing  at  all  for  the  disease  that 
he  may  have  discovered. 

In  some  conditions,  and  amid  some  circumstances,  the  rectum  will 
not  become  inflated.  If  there  is  a  close  stricture  of  the  rectum;  if 
there  is  malignant  growth  or  other  disease  of  the  rectum,  by  means 
of  which  the  gut's  coats  have  become  extensively  filled  and  fixed  with 
an  organized  plastic  exudate;  if  for  some  reason  the  intra-abdominal 
pressure  is  abnormally  increased,  as  it  may  be  by  the  bearing  down  of 
the  patient,  by  enormous  intestinal  flatus,  or  by  ascites;  or.  if  there  is 
an  impinging  uterus,  an  extrarectal  growth  or  extensive  infiltrating 


Fig.  824. — "  A  section  throush  a  hardened  rectum." — Martin. 


disease  of  the  contiguous  textures,  rectal  inflation  by  this  method,  or 
by  any  other  which  is  governed  by  the  same  principle,  is  a  physical 
impossibility.  But  this  need  not  baffle  the  man  bent  on  seeing  by  in- 
strumental aids. 

Practised  as  described,  when  not  embarrassed  by  the  exceptions 
specified,  this  method  will  achieve  its  purpose  and  reveal  to  the  surgeon 
that  the  transverse  diameter  of  the  rectum  is  variable.  Martin  has 
demonstrated  this  variation  by  means  of  a  section  through  a  hardened 
rectum,  with  the  body  in  ]\Iartin's  posture  (Fig.  334).  A^Hhile  in  some 
places  it  is  not  more  than  an  inch  (2.54  centimetres),  in  others  it  is  more 
than  four  times  as  much,  in  diameter. 

The  rectum  may  present  to  the  eye  of  the  imaginative  observer 
the  appearance  of  a  chain  of  urinary  bladders,  communicating  one 
with  another  by  means  of  irregularly  elliptic  openings  set  at  varying 


THE   RECTUM 


811 


axes,  and  bounded  by  the  nonparallel  borders  of  the  rectal  valves.  In 
the  normal  rectum,  the  air  pressure  smooths  the  mucous  membrane 
evenly  over  the  entire  surface  of  the  gut.  The  normal  mucous  mem- 
brane of  the  so-called  ampulla  appears  at  first  wet  and  of  a  shining 
bluish  gray.  As  it  dries,  under  the  influence  of  gravitation  the  blue 
venous  tint  fades  out  of  the  gray,  and  the  wall  becomes  pink-tinged; 
presently,  it  assumes  the  appearance  of  parchment,  and  sometimes  it 
appears  painted  at  rare  intervals  with  ramifying  little  arteries  which 
are  crowded  and  overlapped  by  the  larger  comjoanion  veins;  the  latter 
are  less  arborescent  and  more  suddenly  dive  and  disappear  in  the  bowel 
wall.  In  time,  there  comes  a  sheen  over  all,  and  the  vascular  pictures 
lade.  These  phenomena  appear  exactly  as  described  only  in  the  healthy 
rectum;    in  the  diseased  organ  the  colour  varies  much. 

Should  the  operator  deviate  from  the  prescribed  directions  for  the 
manipxilation  of  his  fingers,  and  so  twist  his  hands  as  to  divulse  the 
anus  in  the  antero-posterior  direction  instead  of  laterally,  he  invites- 
defeat  upon  himself;  for,  in  the  male,  the  fixation  of  the  perineum 
and  the  immobility  of  the  coccyx  interfere  with  the  requisite  dilatation; 
while  in  the  female,  the  extreme  mobility  of  the  perineum,  and  particu- 
larly the  backward  displaceability  of  the  coccyx,  will  allow  such  traction 
to  be  made  upon  the  leva- 
tores  ani  as  to  pull  their 
inner  borders  parallel  and 
almost  together;  and,  in 
consequence,  the  wider 
the  female's  anus  is 
opened  antero  -  posterior- 
ly, the  closer  it  shuts 
laterally  to  rob  one  of 
one's  view. 

Instrumental  Proctos- 
copy.— Special  parapher- 
nalia and  much  practice 
in  their  use  are  necessary 
for  a  rapid,  painless  and 
complete  inspection  of 
the  rectum. 

The  chair  which  is 
shown  in  the  illustra- 
tions *  was  designed  by 
Dr.     T.     C.     Martin,    of 

Cleveland,  to  facilitate  the  placing  of  the  patient  in  a  new  posture 
equivalent  to  tlie  knee-chest  posture.     This  improvement  on  the  Yale 


Fig.  325. — "  Thomas  Charles  Martin's  anoscope." 
— Martin  (page  812). 


*  Much  of  the  mechanism  of  this  excellent  invention  is  necessarily  omitted  in 
the  siriall  dniwinf^s  to  which  alone  space  can  be  <s,\\-(n\.  The  reader  is  referred  to 
Dr.  Martin  for  fnrttier  particulars. — Eijitor. 


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A   TEXT-BOOK   OF  GYNECOLOGY 


Fig.  326. — "The  distinctive  feature  of  this  anoscope  is  the  peculiar 
form  of  its  obturator.'' — Martin. 


chair  consists  of  a  knee-piece  ^dlich  is  fixed  to  the  left  arm,  of  a  mechan- 
ism attached  to  the  running-gear  which  provides  for  the  new  move- 
ments, of  a  shoulder-strap,  and  of  an  illumination  apparatus  which  is 
susceptible  of  adjustment  in  an  infinite  number  of  positions. 

Thomas  Charles  ]\Iartin's  anoscope  (Fig.  335)  consists  of  a  short 
cylindrical  tube  open  at  the  ends.     It  is  2  inches  (5.08  centimetres) 

in  length  and  ^ 
of  an  inch  (2.82 
centimetres)      in 
diameter.        The 
proximal    end    is 
provided   with   a 
trumpet  -  shaped 
expansion  and  a  strong  handle.     The  distinctive  feature  of  this  ano- 
scope is  the  peculiar  form  of  its  obturator  (Fig.  326),  which  has  a 
capacit}'  for  a  multiplicity  of  uses. 

The  obturator  consists  of  a  hard-rubber  cylinder,  in  the  middle  of 
which  is  fixed  a  brass  tube  for  purposes  of  irrigation.  Its  surface  is 
fluted  in  such  a  manner  that  it  may  be  made  to  lock  in  any  of  several 
positions  upon  a  tubercle  within  the  cylinder.  These  flutes  also  pro- 
vide for  escape  from  the  rectum 
of  fluids  and  gases  under  certain 
conditions.  The  contracted  neck 
near  the  distal  end  of  the  obtu- 
rator provides  a  cup  to  facilitate 
the  application  of  ointments  to 
certain  rectal  areas  (Fig.  327). 
This  contracted  neck  is  a  feature 
which  contributes  to  the  instru- 
ment's usefulness  as  a  means  for 
irrigation;  providing,  in  the  one 
case,  a  self-retaining  direct-flow 
irrigator,  and,  in  the  other  case, 
when  locked  in  proper  position, 
an  unobstructed  return-flow  irri- 
gator. Platinum  pins  connect 
the  centrally  placed  brass  tube 
with  the  surface  of  the  neck  of 
the  obturator,  thus  making  the 
instrument  an  anal  electrode. 
The  proctoscope  (Fig.  328)  is 
of  the  same  diameter  as  the  anoscope  and  is  4  inches  (10.16  centi- 
metres) in  length,  which,  because  of  the  displaceability  of  the  pelvic 
floor,  is  usually  sufficient  for  it  to  reach  as  high  as  the  promontory 
of  the  sacrum,  except  in  some  special  instances. 

Special  preliminary  preparation  of  the  patient  is  ordinarily  not  re- 
quired, as  the  usual  condition  of  the  rectum  is  that  of  emptiness.     In 


Fig.  327. — "  The  contracted  neck  .  .  .  provides 
a  cup  to  facilitate  the  application  of  oint- 
ments."— Martin. 


THE   RECTUM 


813 


some  cases,  however,  it  facilitates  the  inspection  if  the  patient  employs 
rectal  lavage  an  hour  before  the  examination. 

The  Technique. — Step  I:  The  patient  should  be  required  to  sit  on 
the  operating  chair  with  her  body  turned  to  the  left  and  facing  the 
knee-board.  The  right 
knee  should  be  crossed 
over  the  left  knee,  the 
left  arm  should  embrace 
the  right  border  of  the 
chair-back,  or  it  may  be 
folded  at  the  side  as  for 
Sims's  posture.  The  small 
pillow  should  be  held  in 
the  patient's  right  hand, 
and  against  and  upon  her 
left  shoulder  (Fig.  339). 

Step  II  requires  that 
the  chair  be  changed  to 
the  horizontal  position  and  the  light  fixture  adjusted  (Fig.  330).  This 
movement  brings  the  patient  into  Sims's  semiprone-semiflexed  posture 
without  requiring  any  movement  whatever  on  the  part  of  the  patient 


Fig.  -328. — "The  proctoscope." — Martin  Tpage  812). 


Fig.  329.— '-The  patient  .should  be  re- 
quired to  sit  on  the  operating  chair." 
— Martin. 


Fig.  330. — "  Step  II  requires  that  the  chair 
be  clianged  to  the  horizontal  position." — 
Martin. 


after  she  is  properly  seated.     In  this  posture  the  external  anus  and 
fixed  rectum  are  to  be  examined. 

(a)  Digital  and  ocular  inspection  sliould  now  be  made  of  the  anal 
verge,  the  extccnal  anus,  and  the  supci-ficial  ischiorectal  space  at  a  mo- 
ment when  the  patient  is  relaxed,  and  again  when  she  is  bearing  down. 


814 


A  TEXT-BOOK  OF  GYNECOLOGY 


Fig.  331. 


-"  Tlie  chair  should  be  tilted, 
(page  815). 


-Martin 


(&)  Digital  examination  of  the  fixed  or  anal  rectum,  also,  should  be 
made  a  preliminary  to  the  introduction  of  the  anoscope. 

(c)  The  anoscope 
should  be  gently  pressed 
into  the  anus  in  the  direc- 
tion of  its  axis  till  the 
sphincters  relax  to  receive 
it.  The  introduction  of 
the  instrument  may  be 
much  facilitated  by  hold- 
ing its  lubricated  end 
against  the  sphincter  and 
requiring  the  patient  to 
bear  down;  bearing  down 
expands  the  ental  sphinc- 
ter, relaxes  the  levator  ani, 
thins  the  pelvic  floor  or 
shortens  the  fixed  rectum, 
and  presses  the  rectal 
sphincter  over  the  instru- 
ment-— in  other  words,  the 
patient's  anus  is  made  to 
climb  down  upon  the  instrument.  After  the  introduction  of  the  ano- 
scope, its  obturator  should  be  removed  and  the  inspection  made.  The 
observations  should 
be  made  coincident 
with  the  withdrawal 
of  the  anoscope.  In 
instances  of  extreme- 
ly sensitive  ani,  hy- 
podermic injection 
into  the  sphincters  of 
10  or  20  minims  of 
one  -  tenth  -  of  -  one  - 
per-cent  solution  of 
cocaine  will  render 
anoscopy  painless. 

A  desire  for  pre- 
cision requires  that 
lesions  of  the  fixed  or 
anal  rectum  sliould 
be  noted  as  occupy- 
ing a  given  quadrant, 
and  as  situated  at  a 
given  zone,  e.  g.,  a 
circumscribed  disease  may  be  described  as  situated  at  the  ental  sphincter 
zone  and  in  the  left  lateral  quadrant. 


Fig.  332.- 


-"  The  extreme  oblique  lateral  position. "- 
(page  815). 


-Martin 


THE   RECTUM 


815 


Fig.  333.— "The  hook."— Martin. 


Step  III  requires  (a)  tliat  the  shoulder  strap  should  be  placed  and 

fixed  to  the  ehair^  that  the  knees  should  be  drawn  up  so  that  the  thighs 

are    at    a    right    angle   to    the 

length   of   the    chair-top,    and 

that  the  chair  should  be  tilted 

(Fig.  331)  to  the  extreme  ob- 
lique lateral  position  (Fig.  332). 

The  leg-foot-board  should  now 

be  lowered,  and  the  operator's 

stool  placed  in  position.     The 

illumination  apparatus  should  next  be  adjusted  as  illustrated.  In  this 
new  posture,  which  is  equivalent  to  the  knee-chest  pos- 
ture, the  abdominal  rectum  is  to  be  examined. 

(b)  Introduction  of  the  proctoscope  requires  sup- 
ported eversion  of  the  buttocks  and  steady  gentle  pres- 
sure of  the  well-lubricated  instrument  upon  the  anus 
in  the  direction  of  the  umbilicus,  until  the  sphincters 
are  felt  to  yield;  or  the  patient  may  be  required  to  bear 
down  to  take  the  speculum.  As  the  instrument  enters 
the  inflatable  movable  rectum,  it  should  be  pointed 
toward  the  promontory  of  the  sacrum  and  subsequently 
into  the  sacral  hollow.  The  withdrawal  of  the  obturator 
is  followed  by  atmospheric  inflation  of  the  rectum. 

(c)  The  operator  should  observe  the  degree  of  rectal 
distention,  the  situation  and  number  of  the  rectal  valves, 
their  propinquity  to  one  another  when  passive,  and  the 
relation  of  one  valve  to  another  at  the  time  of  the 
patient's  bearing  down.  Under  pressure  of  the  procto- 
scope, if  possible,  or  the  hook  (Fig.  333),  if  necessary, 
each  valve  should  be  effaced  or  displaced,  and  in  regular 
order  each  of  the  rectal  chambers  should  be  carefully 
inspected.  A  proctoscopic  mirror  may  be  necessary  for 
viewing  the  supravalvular  surfaces  (Fig.  334). 

The  examination  being  finished,  we  proceed  to — 

Step  IV:  The  proctoscope  should  be  withdrawn,  the 
illumination  apparatus  fixed  in  the  first  position,  the 
leg-foot-board  lifted  to  its  place,  the  lever  extended,  the 
crank  turned,  and  the  chair  carried  back  to  the  hori- 
zontal and  upright  positions;  the  patient  being  thus  re- 
turned to  her  feet  by  the  execution  in  the  reverse  order 
of  the  several  steps  described. 

This  method  of  inspection  does  not  subject  the  pa- 
tient to  struggle  or  strain  and  need  excite  no  embar- 
rassment. 

Observation  by  this  metliod  teaches  that,  in  nearly  all 
cases  of  disease  at  the  anus,  there  is  congestion  of  the  rectal  mucous  mem- 
brane, and  that,  not  unusually,  a  diffused  proctitis  attends  anal  diseas(>. 


816 


A   TEXT-BOOK   OF   GYNECOLOGY 


Those  cases  in  which  there  is  no  apparent  lesion  at  the  anus,  and 
which  are  in  a  perfunctory  way  sometimes  declared  to  be  catarrh  of  the 
rectum,  will  at  once  have  their  real  cause,  such  as  a  high-up  rectal  poly- 
pus or  a  congenital  or  organic  stricture  or  ulceration,  positively  diag- 
nosticated, and  will  be  made  accessible  for  intelligent  treatment. 

New  growths  or  ulcerations  may  be  seen  and,  by  means  of  a  long- 
handled  curette,  scrapings  made,  in  order  that  the  microscopist  may 
determine  their  exact  character. 

Vesico-rectal,  vagino-rectal,  and  deeper  rectal  fistulge,  are  often  ap- 
parent at  a  glance,  but,  in  any  case,  may  be  discovered  by  the  use  of 
the  proctoscopic  mirror. 

The  existence  of  stricture  of  the  rectum  need  no  longer  be  regarded 
as  only  doubtful,  and  this  method  proves  positively,  even  to  the  casual 
observer,  how  fallacious  is  the  rectal  sound  as  usually  employed  in  the 
diagnosis  of  stricture.  It  has  been  repeatedly  shown  how  easy  it  is 
for  an  entering  or  returning  bulb-sound  to  be  caught  and  held  by  the 
rectal  valves,  and  to  elicit  those  signs  which  are  generally  considered 
diagnostic  of  organic  stricture  of  the  rectum. 

The  rectal  valve  constitutes  the  chief  topographical  feature  of  the 
abdominal  rectum.  Its  histologic  character  indicates  it  as  the  typical 
anatomic  valve  (Fig.  335).  The  attached  border  of  each  valve  spans  a 
little  more  than  half  the  circumference  of  the  rectum,  and  its  free 
border  projects  half  way  across  the  diameter  of  the  inflated  rectum. 
Thus,  what  has  heretofore  been  regarded  as  a  cavernous  ampulla,  is 

seen  to  be  divided  in- 
to several  chambers. 
There  are  as  many 
chambers  in  the  rec- 
tum as  there  are  rec- 
tal valves.  The  num- 
ber of  rectal  valves  is 
variable.  Some  sub- 
jects have  but  two, 
others  have  four, 
but  90  per  cent  of 
persons  possess  three. 
The  uppermost  valve 
is  invariably  situated 
at  the  juncture  of  the 
rectum  and  the  sig- 
moid flexure,  and  is  usually  on  the  left  wall;  the  next  is  on  the  right, 
and  the  lowermost  on  the  left  wall.  The  positions  of  the  lower  two 
valves  are  sometimes  anterior  and  posterior  respectively.  It  must  be 
readily  seen  that  the  newer  methods  of  rectal  inflation  for  rectal  in- 
spection will  determine  newer  notions  of  the  topography  of  this  part, 
and  will  justify  consideration  of  the  lowermost  chamber  as  the  first 
rectal  chamber;  of  the  cavernous  area  beyond  the  first  valve  and  be- 


Fici.  335. — "The  typical  anatomic  valve.'"  . I,  mucous  mem- 
brane; B,  fibrous  tissue  ;  C,  bundles  of  circular  muscular 
fibres ;  D,  F,  arteries;  E,  G,  veins  ;  H,  areolar  and  adipose 
tissue. — Mabtin. 


THE   RECTUM 


81Y 


Fig.  336. — "  The  ancient  arbitrary  division  of  the  rectum 
should  be  abandoned."  (Laparosymphysiotomy,  show- 
ing the  rectum  packed  with  scybala.) — Martin. 


low  the  second,  as  the  second  chamber;  and  of  the  upper  chamber  as 
the  third  or  perhaps  the  fourth,  according  to  the  number  of  valves. 
The  ancient  arbitrary  division  of  the  rectum  by  the  anatomists  into 
upper    first,    middle 
second,     and     lower 
third  parts,  should  be 
abandoned  (Fig.  336). 

If  this  method  of 
ocular  examination 
is  practised,  there 
need  be  no  longer 
any  excuse  for  calling 
an  undiagnosticated 
disease  of  the  rectum 
an  "obscure disease"; 
and,  whatever  the 
disease  present,  this 
method  makes  it  sus- 
ceptible of  demon- 
stration to  the  pa- 
tient's   physician    or 

attendant  friend.  There  is  no  necessity  whatsoever  that  the  diag- 
nosis of  rectal  disease  be  taken  on  faith.  (Complete  Inspection  of  the 
Eectum,  Thomas  Charles  Martin,  M.  D.,  American  Gynecological  and 
Obstetrical  Journal,  December,  1898.) 

Displacements  of  the  rectum  in  women  may  be  classified  as  (a) 
anterior,  (b)  posterior,  and  (c)  prolapse.  Anterior  displacement  con- 
sists of  the  sacculation  forward  of  the  anterior  wall  of  the  rectum. 
This  constitutes  the  condition  of  rectocele  (see  Eectocele),  or  more 
specifically  anterior  rectocele.  It  necessarily  implies  an  equal  displace- 
ment of  the  posterior  wall  of  the  vagina.  The  condition  is  generally 
induced  by  either  dilatation  of  the  vaginal  outlet  or  injury  of  the 
pelvic  floor.  It  is  treated  as  prescribed  in  the  chapter  on  Kepair  of 
Surgical  Injuries  of  the  Floor  of  the  Pelvis. 

Posterior  displacement  of  the  rectum  consists  in  the  sacculation, 
posteriorly,  of  the  posterior  wall  of  the  rectum,  and  is,  in  reality,  a 
posterior  rectocele  (Fig.  337).  This  condition  which  is  not  frequently 
recognised,  is,  nevertheless,  one  of  relatively  common  occurrence. 
Its  symptoms  consist  of  more  or  less  rectal  tenesmus  and  difficulty  in 
defecation,  there  being  a  constant  sense  of  the  presence  of  residual 
faeces  after  an  effort  at  dejection.  If  the  bowel  is  loaded  with  hard- 
ened fffical  matter,  much  difficulty  is  experienced  in  discharging  it,  the 
effort  being  attended  with  a  feeling  of  retro-anal  protrusion.  If  a 
patient  afflicted  witli  this  condition  is  placed  in  either  the  dorsal  or 
the  semiprone  position  and  is  asked  to  strain,  a  fulness  behind  the 
anus  will  !)<■  ;ip|i;iivii1.  Kectal  exploration  by  the  finger  will  reveal  a 
posterior  sacculaLi(jn  of  the  rectum,  just  within  the  external  sphincter. 


818 


A   TEXT-BOOK   OF   GYNECOLOGY 


and  associated  with  a  diminution  or  a  disappearance  of  the  normal 
constriction  due  to  the  proper  action  of  the  levator  ani  muscle.  The 
pathology  of  this  condition  is  essentially  that  of  the  dilatation  of  the 
rectum  and  is  due  to  either  a  relaxation  or  an  injury  of  the  deep  mus- 
cular layer  of  the  pelvic  floor. 
When  the  levator  ani  has  once 
been  damaged,  and  the  rectum 
has  been  deprived  of  its  support, 
there  occurs  more  or  less  descent 
of  the  bowel.  This  descent  is  aug- 
mented by  an  effort  to  defecate. 
The  external  sphincter  fails  to  act 
properly  because  the  descending 
fffical  matter  is  to  a  certain  extent 
diverted  from  its  course  and  conse- 
quently fails  to  exercise  the  proper 
dilating  influence  iipon  the  exter- 
nal muscle.  The  treatment  con- 
sists (1)  in  restoring  the  integrity 
of  the  parts  upon  the  damage  to 
which  the  rectal  displacement  de- 
pends, and  (2)  in  restoring  the  rec- 
tum itself  to  its  normal  position. 
Reed  has  operated  in  these  cases  by 
means  of  the  Emmet  operation  for 
deep  lacerations  of  the  perineum, 
supplemented  by  the  following  steps:  An  incision  is  made  transversely 
midway  between  the  anus  and  the  tip  of  the  coccyx,  care  being  taken 
to  avoid  the  external  sphincter.  This  incision,  which  is  about  an 
inch  and  a  half  long,  but  which  may  be  longer,  if  required,  is  carried 
down  to  the  posterior  wall  of  the  rectum,  which  is  then  dissected  up 
to  a  point  beyond  the  levator  ani.  The  sacculated  bowel  is  then  lifted 
above  the  levator  to  which  it  is  attached  by  a  few  interrupted  catgut 
sutures.  The  external  incision  is  then  closed.  Harris's  operation  for 
deep  injuries  of  the  muscular  floor  of  the  pelvis  may  be  substituted 
with  advantage  for  the  Emmet  operation  in  these  cases. 

Prolapsus  of  the  rectum  may  be  either  (1)  partial,  or  (2)  com- 
plete. By  partial  prolapse  is  implied  merely  a  descent  and  extrusion 
from  the  anus  of  the  mucous  membrane  of  the  rectum,  and  it  is  the 
condition  generally  designated  prolapsus  ani;  complete  laceration  im- 
plies the  descent  and  extrusion  from  the  anus  of  the  entire  rectal 
walls,  and  is  the  condition  ordinarily  designated  prolapsus  recti.  Par- 
tial prolapsus  occurs,  for  the  most  part,  in  children,  and  is  caused  by 
efforts  at  defecation,  either  in  constipation,  or  in  diarrhoea  associated 
with  rectal  irritation  and  consequent  tenesmus.  Complete  prolapse 
occurs  more  frequently  in  adults  and  is  the  result  of  straining  at  stool, 
either  from  constipation,  vesical  tenesmus  induced  by  stone  in  the 


Fig.  337. — "  Posterior  rectocele." — Eeed 
(page  817). 


THE  RECTUM  819 

bladder  or  other  causes,  uterine  displacements  caused  by  polypi,  etc. 
Injuries  of  the  pelvic  floor,  relaxation  of  the  muscular  apparatus  of 
the  rectum,  and  general  enteroptosis,  are  to  be  considered  as  predispos- 
ing causes.  The  symptoms  of  prolapsus  of  the  rectum,  whether  com- 
plete or  incomplete,  consist  in  the  sudden  appearance  of  a  mass  just 
outside  the  anal  orifice,  which,  upon  examination,  will  be  found  to 
consist  of  folds  of  mucous  membrane.  If  this  extrusion  is  recent  and 
the  sphincteric  contraction  is  not  extreme,  the  mass  may  present  a 
ruddy  hue,  but,  if  the  case  has  been  one  of  long  standing,  it  may  be 
dark  in  appearance,  or  even  gangrenous.  The  diagnosis  is  self-evi- 
dent, but  is  easily  confirmed  by  introducing  the  anointed  finger  into 
the  anus.  , 

The  treatment  may  be  either  (1)  palliative  or  (2)  radical.  The 
palliative  treatment  consists  in  the  immediate  return  of  the  parts. 
This  is  accomplished  in  children  by  placing  the  patient  upon  her  side, 
anointing  the  fingers  of  one  hand  with  some  sterilized  preparation, 
and  then  by  gentle  pressure  replacing  the  extruded  mucous  mem- 
brane. An  anal  compress  may  be  applied  following  the  replacement 
of  the  bowel.  In  some  cases,  however,  the  extrusion  may  have  ex- 
isted for  so  long  a  time,  and  the  sphincteric  constriction  may  have 
been  so  extreme,  that  strangulation  with  death  of  the  structures  may 
have  ensued.  It  is  to  be  remembered  that,  both  in  complete  and 
incomplete  prolapse  of  the  rectum,  spontaneous  amputation  of  the 
extruded  part  occasionally  occurs,  resulting  in  the  cure  of  the  patient. 
When  the  condition  has  gone  to  the  stage  that  threatens  this  result, 
intervention  because  of  its  probable  danger,  is  of  questionable  value. 
By  the  slow  amputation  of  the  extruded  rectum,  there  occurs  a  fixa- 
tion by  inflammatory  process  of  the  remaining  intra-anal  segment ; 
and  it  is  obvious  that,  if  this  fixation  is  disturbed,  there  may  occur 
a  retraction  of  the  upper  portion  of  the  rectum,  resulting,  in  the 
event  of  cure,  in  the  deposit  of  a  zone  of  cicatricial  tissue  and  the 
development,  later,  of  intractable  stricture.  If,  however,  in  the  event 
of  complete  prolapsus,  there  is  a  reasonable  prospect  of  saving  the 
bowel,  the  patient  should  be  placed  in  either  the  knee-chest  or  the 
semiprone  posture,  and  the  bowel  should  be  replaced  by  digital 
manipulation.  If  this  is  not  practicable  because  of  intractable  sphinc- 
teric spasm,  an  ansesthetic  should  be  given  to  the  patient.  Divulsion  of 
the  sphincter,  which  would  facilitate  the  reduction  of  the  bowel,  is 
not  desirable,  for  the  reason  tbat  the  sphincter,  in  its  full  tone  and 
integrity,  is  required  to  maintain  the  replaced  bowel  in  position.  For 
the  purpose  of  restoring  the  normal  contractility  of  the  relaxed  bowel, 
it  has  been  recommended  to  cauterize  it  in  spots  with  either  the  silver 
nitrate  or  the  cautery.  A  recta]  tube  of  soft  rubber  may  be  used  to 
maintain  the  reduction.  In  exceedingly  obstinate  cases,  a  V-shaped 
piece  has  been  removed  from  the  sphincter,  the  apex  of  the  letter 
pointing  backward  toward  the  coccyx,  the  sphincter  being  restored 
after   rfifliiniion    of   th(;   bowel.      Jaennel,   of   Toulouse    {Bulletin   de 


820  A  TEXT-BOOK   OF  GYNECOLOGY 

VAcacUmie  de  medecine),  believes  that  rectal  prolapse  is  due,  in  many- 
cases,  to  a  weakening  of  the  ligaments  that  hold  these  parts  in  posi- 
tion, especially  the  mesocolon  and  the  mesorectum,  establishing  the 
condition  to  which  allusion  has  already  been  made  as  that  of  enterop- 
tosis.  He  treats  this  condition  by  performing  an  ordinary  colotomy. 
The  sigmoid  liexure  is  sought  for,  drawn  upward,  and  fixed  to  the 
abdominal  wall  by  sutures.  The  next  step  is  to  establish  an  artificial 
anus,  which  will  afford  the  necessary  rest  until  firm  adhesion  has  oc- 
curred. The  opening  is  not  closed  until  the  flexure  has  become  firmly 
adherent.  The  operation  has  been  performed  with  entire  success  in 
one  case,  the  patient  being  cured  in  two  months.  It  was  performed 
in  three  sittings  and  this  is  one  of  its  disadvantages ;  besides,  it  is  not 
easy  to  find  the  sigmoid  flexure.  It  has  the  advantage  over  other 
operations  for  rectal  prolapse,  however,  in  that  it  removes  the  cause 
of  the  trouble  and  is  less  dangerous.  It  is  contraindicated  in  recent 
cases  of  medium  severity  or  in  old  cases  in  which  the  prolapse  is  due 
to  inflammatory  peritoneal  adhesions. 

General  Etiology  of  Rectal  Disease. — Because  of  its  peculiar  func- 
tion, the  rectum  frequently  becomes  diseased.  There  are  so  many 
factors  entering  into  the  etiology  of  rectal  disease  that  we  shall 
not  attempt  to  mention  them  all.  There  is  little  doubt  that  the 
upright  position  assumed  by  man  is  a  predisposing  cause  of  hemor- 
rhoids, because  a  large  amount  of  blood  is  thereby  thrown  upon  the 
valveless  veins  of  the  rectum.  The  most  common  of  all  causes,  is 
consfipation  induced  by  irregularities  in  sleeping,  eating,  exercising, 
and  attending  to  the  calls  of  Nature.  Fissure  is  usually  the  result  of 
constipation  in  consequence  of  a  tear  made  in  the  mucous  membrane 
during  the  passage  of  hardened  fseces ;  ulceration,  because  of  pressure 
of  the  faecal  mass  on  the  blood  vessels  causing  necrosis;  hemorrhoids 
ensue  because  of  pressure  interfering  with  the  return  flow  of  blood 
and,  further,  as  a  result  of  straining  coincident  with  their  expulsion; 
prolapsus  and  invagination  are  of  frequent  occurrence  in  the  consti- 
pated on  account  of  straining  and  the  dragging  down  of  the  bowel 
by  the  fasces.  The  mucous  membrane  of  the  rectum  is  very  fragile 
and  is  occasionally  injured  sufficiently  by  the  faecal  concretions  to  set 
up  a  proctitis  which  may  confine  itself  to  the  rectum  or  extend  into  the 
circumrectal  tissue  causing  ischiorectal  alyscess  and  fistula.  Neuralgia 
of  the  rectum  is  now  and  then  a  symptom  of  costiveness  and  results 
from  the  nerves  being  caught  between  bony  structures  on  the  one 
hand,  and  a  faecal  mass  on  the  other. 

Strong  drink  and  other  forms  of  dissipation  are  responsible  for 
many  of  the  ailments  in  this  locality.  Persons  suffering  from  pruritus 
and  hemorrhoids  are  invariably  worse  after  a  spree.  The  continued 
use  of  purgatives  is  a  common  cause  of  rectal  disease,  owing  to  the 
straining  and  irritation  of  the  mucous  membrane  induced  by  them. 
Clironic  diarrlma  may  incite  a  prolapsus,  ulceration,  or  hemorrhoids, 
on  account  of  the  frequent  stools,  tenesmus,  and  passage  over  the 


THE  RECTUM  821 

sensitive  membrane  of  irritating  discharges.  Threadworms,  pediculi, 
and  anal  eczema,  not  infrequently  start  an  itching  about  the  anus 
which  is  difficult  to  arrest.  Constipation,  stricture,  and  fissure,  in 
young  children  can  usually  be  traced  to  a  congenitally  narrow  anus. 

Foreign  hodies  reaching  the  rectum  by  way  of  the  mouth  or  anus 
cause  considerable  suffering  and  may  require  an  operation  to  remove 
them.  Traumatism  caused  by  hardened  fasces  or  operation  is  respon- 
sible for  many  of  the  afflictions  in  the  terminal  colon.  The  Whitehead 
operation,  when  primary  union  is  not  obtained,  results  in  many  un- 
pleasant sequelae  such  as  ulceration,  stricture,  fistula,  abscess,  pruritus, 
and  incontinence;  other  operations  may  do  the  same,  but  only  at  rare 
intervals.  Many  injuries  of  the  rectum  follow  the  frequent  and  careless 
introduction  of  the  syringe  nozzle  by  the  person  in  the  habit  of  taking 
enemata. 

Occupation  is  an  important  factor  in  the  causation  of  rectal  dis- 
ease. Persons  whose  employment  requires  a  sedentary  life,  their 
being  constantly  on  their  feet,  or  irregular  hours  for  eating  and  attend- 
ing to  Nature's  demands,  are  frequent  sufferers  from  hemorrhoids  and 
fissures.  The  upright  position  assumed  by  conductors,  brakemen, 
engineers,  and  motormen,  combined  with  the  irregular  jarring  motion 
of  trains  and  street  cars,  is  a  predisposing  cause  of  rectal  disease.  On 
account  of  the  vascular  arrangement,  obstructive  diseases  of  the  liver 
and  heart  are  usually  accompanied  by  hemorrhoids.  Tumours  in,  or 
displacements  of,  neighbouring  organs,  as  an  enlarged  prostate  or  a 
retroverted  uterus,  are  the  cause  of  many  patients  going  to  the  proc- 
tologist. The  function  of  the  rectum  renders  it  liable  to  injury,  thus 
preparing  the  way  for  infection,  local  and  general,  by  the  various 
micro-organisms  contained  within  its  walls.  Venereal  diseases  com- 
mon in  the  sexual  organs  are  found  also  in  the  rectum  and  about  the 
anus  of  those  who  practise  pcederasty  (rectal  intercourse),  but  with 
less  frequency.  Pederasts  are  recognised  by  their  relaxed  sphincters 
and  the  funnel  shape  of  the  anus.  The  large  rectal  veins  in  passing 
from  without  the  bowel  to  the  mucous  membrane  within,  go  through 
muscular  buttonholes.  It  is  believed  by  some  that  frequent  muscular 
contraction  around  the  veins  results  in  their  enlargement  below,  ter- 
minating in  piles.  Occasionally  the  levator  ani  and  external  sphincter 
become  hypertrophied  and  irritable  as  the  result  of  a  faecal  mass 
pounding  upon  them,  and  thus  interfere  with  defecation  or  cause 
nmch  pain  by  their  frequent  contractions.  Undue  force  exhibited  by 
the  abdominal  muscles  will  produce  an  engorgement  of  the  rectal 
veins;  this  can  be  demonstrated  by  having  a  patient  suffering  with 
hemorrhoids  strain  down,  when  they  will  immediately  enlarge  and 
turn  blue.  Houston's  folds  sometimes  become  hypertrophied,  result- 
ing in  constipation  iinrl  iillied  niliiu'nts. 

The  Relation  of  Intrapelvic  Disease  to  Disease  of  the  Rectum  in 
Women. — Tntrapclvic  disease  in  women  may  disorganize  the  function 
or  compromise   Uic    iniogrity   of   tlio   rectum.      Such   results   are   the 


822 


A   TEXT-BOOK  OF  GYNECOLOGY 


product  of  (1)  pressure  upon  the  rectum  by  means  of  a  displaced 
uterus  or  ovary,  or  of  a  tumour  or  adventitious  peritoneal  band;  (3) 
the  extension  of  an  infl.ammation ;  (3)  adhesion  of  a  viscus  to  the 
rectum  or  sigmoid  flexure,  or  of  adhesion  of  one  part  of  the  gut  to 
another. 

Pressure  on  the  normal  rectum  of  a  retroposited  but  nonadherent 
uterus  will  not  often  obstruct  the  descent  of  the  faeces  provided  urina- 
tion precedes  the  attempt  at  defecation.  An  ovary  prolapsed  into  the 
cul-de-sac  will  interfere  with  defecation,  inasmuch  as  its  sensitiveness  to 
pressure  arrests  the  voluntary  effort  of  the  patient.  An  intrapelvic 
tumour,  nonadherent  to  the  rectum,  obstructs  defecation  in  propor- 
tion as  it  limits  the  dilatation  of  the  rectum;  the  same  may  be  said 
of  an  adventitious  band  of  peritoneum  about  the  rectum.  The  pres- 
ence of  any  of  these  con- 
ditions may  interfere 
with  the  nutrition  of  the 
rectum  or  obstruct  its 
circulation  and  provoke 
l^roctitis,  ulceration,  and 
hemorrhoids,  and  render 
the  rectum  prone  to  other 
diseases. 

Inflammation  of  any 
pelvic  viscus,  pelvic  peri- 
tonitis, appendicitis,  or 
pelvic  cellulitis,  by  reason 
of  the  usually  concomi- 
tant proctitis  and  infil- 
tration of  the  rectal 
valves,  produces  a  transi- 
tory diarrhoea,  constipa- 
tion, or  obstipation;  if 
resolution  is  imperfect, 
the  obstipation  will  be- 
come chronic — in  such  a 
condition  there  is  always 
a  remote  possibility  of 
acute  and  complete  ob- 
struction from  inflamma- 
tion and  oedema  of  the 
aifected  rectal  valve.  In- 
trapelvic abscess  finds  its 
quickest  avenue  of  escape  into  the  rectum.  This  event  is  character- 
ized by  amelioration  of  the  patient's  symptoms  and  subsequent  puru- 
lent discharge  from  the  rectum.  Proctoscopy  reveals  a  more  or  less 
general  proctitis  and,  at  the  vicinity  of  the  fistula,  an  oedema  and 
corrugation  of  the  mucou.s  membrane;  if  the  perforation  is  not  at 


Fig.  338. — "  Adhesions  to  the  rectum,  and  particularly 
to  the  sigmoid  flexure,  may  arrest  the  descent  of 
fseces."  (The  dotted  portion  shows  an  adhesion 
which  has  been  broken  up.) — Maetin  (page  823). 


THE   RECTUM  823 

once  visible^  pressure  on  the  abdomen  will  cause  pus  to  be  ejected  at 
its  site. 

Adhesions  to  the  rectum,  and  particularly  to  the  sigmoid  flexure, 
may  arrest  the  descent  of  solid  or  semisolid  faeces  without  contracting 
the  bowel's  lumen;  inasmuch  as  the  immobilization  of  a  portion  of  an 
organ  which  is  essentially  peristaltic,  robs  that  portion  involved,  of  its 
intrinsic  power  of  propulsion  of  its  contents  (Fig.  338).  JSTonperistalsis 
of  the  rectum  by  reason  of  adhesion  to  a  pelvic  viscus  is,  however,  but  a 
minor  factor  in  the  resulting  obstipation,  because  the  expulsion  of 
solid  and  semisolid  faeces  is  in  the  main  accomplished  by  the  volun- 
tary mechanism.  In  case  of  such  adhesion,  the  adherent  organ  inter- 
feres with  the  necessary  dilatation  of  the  rectum,  and,  furthermore, 
the  voluntary  forces  of  defecation  drive  the  adherent  organ  into  the 
sacral  hollow  ahead  of  the  faecal  mass. 

Grant  observes  that  disease  occurring  in  either  the  genitalia  or  the 
rectum  frequently  manifests  itself  in  the  other  organ  because  of  the 
intimate  relation  of  the  veins,  nerves,  muscles,  and  lymphatics,  sup- 
plying them.  There  are  certain  diseases  that  interfere  with  the  cir- 
culation, and  result  in  congestion  or  anaemia  of  the  rectum,  genitals, 
or  both.  Pain  from  disease  in  the  vagina,  uterus,  ovaries,  tubes  or 
bladder,  is  frequently  reflected  to  the  rectum  and  vice  versa.  Fissure 
or  ulceration  of  the  rectum,  exciting  contraction  of  the  external 
sphincter  or  levator  ani  muscles,  causes  similar  contractions  in  the 
vagina  and  vulva.  Pain  following  operations  about  the  perineum  and 
vagina  is  less  when  the  sphincter  is  divulsed.  Because  of  these  fre- 
quent muscular  contractions,  the  arrangements  of  veins  in  plexuses, 
and  the  intimate  relation  of  the  lymphatics,  the  exchange  of  infections 
from  the  genitals  to  the  rectum,  and  vice  versa,  is  quite  frequent. 
Careful  examination  should  be  made  both  of  the  genitals  and  the  rec- 
tum in  all  obscure  diseases  affecting  either. 


CHAPTER  LI 

INFECTIONS   OF  THE   RECTUM 

Inflammation — Periproctitis ;  Ischiorectal  abscess — Gonorrhoea — Syphilis — Tuber- 
culosis— Surgical  conditions  resulting  from  infections — Anal  ulcer  or  fissure — 
Ulceration  of  the  rectum — Fistula — Stricture. 

Infections  of  the  rectum  may  be  classified  as  (a)  mixed,  and  (h) 
specific.  Mixed  infections,  i.e.,  those  in  whicli  the  various  pus-formers — 
e.  g.,  Staphylococcvs  pyogenes  aureus,  the  various  streptococci,  and  occa- 
sionally the  migrated  Bacillus  coli  communis — are  found,  are  those  that 
are  manifested  in  the  superficial  inflammations,  both  catarrhal  and  fol- 
licular, and  in  deeper-seated  inflammations,  as  periproctitis  and  ischio- 
rectal abscess.  The  specific  infections  which  will  be  considered  in 
this  connection  are,  gonorrhoea,  syphilis  and  tuberculosis. 

Inflammation  of  the  rectum  and  sigmoid  is  a  common  ailment,  and 
one  easily  recognised  and  treated  by  means  of  the  colon  tube.  Ordi- 
narily, the  inflammation  is  confined  to  the  mucous  membrane,  but 
occasionally  it  extends  through  the  muscular  coats  causing  periproc- 
titis, ischiorectal  abscess,  and  fistula.  It  is  frequently  the  result  of  a 
more  serious  disease;  occasionally,  it  is  due  to  diphtheria  and  a  mem- 
brane forms;  again,  because  of  proximity  of  the  vagina  to  the  rectum, 
it  is  caused  by  gonorrhoeal  infection;  while,  in  tropical  countries,  it 
is  often  the  result  of  a  dysentery.  Usually  the  mucous  membrane  will 
be  inflamed  and  dry — atrophic  catarrh — or  spongy  and  smeared  over 
with  an  abundance  of  mucus — hypertrophic  catarrh.  It  may  be  either 
acute  or  chronic.  Children  are  subject  to  the  acute,  and  old  persons  to 
the  chronic  form;  the  former  because  of  diarrhoea,  and  the  latter,  as  a 
consequence  of  loss  of  tonicity  resulting  in  faecal  accumulations.  It 
may  be  caused  by  exposure  to  cold,  sitting  on  damp  steps,  or  traumatism 
due  to  swallowing  a  hard  indigestible  substance  or  to  an  o]3eration. 
Not  infrequently,  it  is  brought  about  as  the  result  of  an  irritable  dis- 
charge from  a  stricture,  cancer,  ulceration,  polypus  or  diarrhoea.  Again, 
it  sometimes  follows  the  administration  of  drugs  such  as  large  doses  of 
mercury  and  arsenic  and  strong  purgatives. 

Symptoms. — The   symptoms   of   inflammation   of  the   rectum  and 

sigmoid  may  be  briefly  summed  up  as  follows — viz.,  severe  tenesmus 

and  sense  of  weight  and  fulness  in  the  rectum;    sensations  of  heat, 

fulness,  and  soreness  on  pressure;    frequent  discharges  of  mucus  and, 

824 


INFECTIONS  OP   THE   RECTUM  825 

occasionally,  of  pus;  spasmodic  and  unsuccessful  attempts  to  evacuate 
the  bowel.  When  due  to  atrophy  following  catarrh,  the  skin  and 
mucous  membrane  about  the  anus  are  dry,  harsh,  and  full  of  cracks; 
when  to  hypertrophy  associated  with  catarrh,  there  will  be  a  constant 
moisture  in  this  locality.  There  is  often  pruritus  due  to  irritating  sub- 
stances getting  into  the  cracks,  and  to  irritation  of  the  skin  and  mem- 
brane caused  by  the  discharge.  In  the  acute  stage  there  is  a  desire  to 
micturate  often,  and,  occasionally,  incontinence  of  urine.  Because  of 
straining  and  frequent  stools,  a  prolapse  of  the  mucous  membrane  is 
not  uncommon.  If  the  inflammation  is  complicated  by  ulceration, 
bleeding  may  be  a  symptom,  or  fsecal  matter  may  get  under  the  mem- 
brane and  start  an  abscess  resulting  in  fistula.  In  general,  any  symp- 
tom present  in  inflammation  of  any  part  of  the  intestine  may  be  pres- 
ent here,  such  as  radiating  and  reflected  pains  and  slight  elevation 
of  the  temperature. 

Prognosis. — When  taken  in  hand  early,  inflammation  of  the  rectum 
and  sigmoid  is  easy  to  control.  An  acute  attack  may  last  one,  two,  or 
three  weeks,  and  the  chronic  form  indefinitely,  depending  upon  the 
cause  and  its  removal.  When  it  has  not  existed  more  than  a  few 
weeks,  the  most  apparent  change  in  the  former,  barring  the  congested 
appearance  of  the  mucous  membrane,  is  the  oozing  of  blood  from  many 
points  when  the  speculum  or  colon  tube  is  introdiiced.  In  cases  of 
long  standing,  the  mucosa  becomes  thickened,  indurated,  and  loses 
its  sensibility  in  a  measure,  so  that  a  considerable  amount  of  fseces  may 
collect  in  the  sigmoid  and  upper  rectum  before  a  warning  is  given 
of  an  approaching  stool.  Inflammation,  when  allowed  to  run  an  un- 
interrupted course,  usually  results  in  ulceration  and  stricture. 

Treatment. — Eemove  at  the  earliest  opportunity  the  source  of  irri- 
tation. Discard  harsh  and  indigestible  foods  for  milk,  soft-boiled  eggs, 
soups,  beef  juice,  and  other  nourishing  fluid  and  semisolid  foods. 
Insist  upon  the  discontinuance  of  eatables  fried  in  grease,  and  those 
that  are  highly  seasoned,  and  at  the  same  time  stop  all  alcoholic 
drinks.  These  patients  must  have  regular  hours  for  eating,  sleeping, 
exercising,  and  attending  to  the  calls  of  Nature.  Keep  the  stools  soft 
with  two  ounces  of  Carabaiia  water  taken  before  breakfast,  and  clear 
the  bowel  of  offending  scybala,  by  massage,  high  enemas,  Epsom 
salts,  Seidlitz  powders  or  other  mild  laxatives,  and,  above  all,  discon- 
tinue irritating  purgatives.  Keep  the  patients  in  bed  as  much  as  their 
circumstances  will  permit.  The  medical  treatment  consists  in  apply- 
ing soothing,  antiseptic,  and  astringent  solutions,  emulsions  and  pow- 
ders, directly  to  the  affected  part  by  means  of  the  colon  tube,  applica- 
tor, atomizer,  and  insufflator.  The  remedies  which  give  the  most  sat- 
isfactory results  are  the  nitrate  of  silver,  balsam  of  Peru,  sulphate  of 
zinc,  lead,  alum,  argonin,  and  ichthyol,  alone  or  in  combination.  Gant 
is  partial  to  the  fluid  extract  of  krameria,  half  an  ounce  to  two  ounces  of 
distilled  water,  thrown  into  the  sigmoid  or  rectum  and  allowed  to 
remain  there  as  long  as  it  can  with  comfort  to  the  patient.    In  aggra- 


826  A   TEXT-BOOK  OF  GYNECOLOGY 

vated  cases,  the  krameria  may  be  increased  to  an  ounce  and  a  half, 
and  the  water  increased  in  proportion.  The  treatments  should  be  given 
two  or  three  times  weekly.  When  the  intestine  is  chafed  and  irritable 
and  tends  to  bleed,  Gant  has  the  patients  use,  on  the  remaining  days, 
enemata  of  an  emulsion  composed  of  olive  oil,  2  ounces,  and  sub- 
nitrate  of  bismuth,  half  a  drachm,  or  nitrate  of  silver  60  grains,  to 
the  pint.  When  the  inflammation  is  caused  by  threadworms  it  can  be 
quickly  subdued  by  a  few  copious  injections  of  salt  or  limewater; 
santonin  may  be  administered  if  the  case  justifies  it.  When  due  to 
gonorrhoeal  virus,  frequent  irrigation  of  the  bowel  with  hot  water  or 
bichloride,  1  to  6,000,  as  hot  as  it  can  be  borne,  will  be  followed  by 
gratifying  results.  In  a  general  way,  the  treatment  consists  in  keeping 
the  bowels  open  and  correcting  errors  in  diet,  together  with  frequent 
hot  and  cold  irrigations. 

Periproctitis;  Ischiorectal  Abscess. — Frequently,  an  inflammation 
starting  in  the  mucous  membrane  extends  through  the  rectal  wall  into 
the  loose  tissues  around  it,  causing  a  diffused  or  circumscribed  peri- 
proctitis resulting  in  ischiorectal  abscess.  Gant  is  of  the  opinion  that 
this  condition  is  made  possible  through  the  intestinal  bacteria  (probably 
the  colon  bacillus)  having  pyogenic  properties,  escaping  into  the  blood 
vessels  or  lymphatics  as  a  result  of  erosion  of  the  mucous  membrane. 
Another  evidence  of  this  is  the  fact  that  the  pus  from  nearly  all,  if  not 
all,  ischiorectal  abscesses  contains  the  colon  bacillus  in  large  num- 
bers. In  addition  to  the  symptoms  of  a  simple  inflammation  of  the 
rectum,  we  now  have  those  of  a  constitutional  character,  as  a  chill, 
high  temperature,  quick  pulse,  restlessness,  and  in  fact  all  the  phe- 
nomena of  pus  formation.  Circumrectal  inflammation  may  be  caused 
by  an  operation  with  resulting  infection,  or  by  the  breaking  down  of 
tuberculous  deposits. 

Treatment. — Powell  claims  to  abort  ischiorectal  abscess  by  deep  in- 
jections of  carbolic  acid.  Gant  has  not  tried  this  plan,  but  has  been  in 
the  habit  of  using  the  ordinary  palliative  meassures  until  there  is  evi- 
dence of  pus  formation.  He  then  opens  the  abscess  by  a  free  incision, 
breaks  up  all  pockets  with  the  finger,  curettes  out  all  gangrenous 
tissues,  and  then  swabs  out  the  cavity  with  carbolic  acid  and  packs  it 
with  sterile  gauze.  The  dressings  are  removed  whenever  they  are 
soiled;  the  Avound  is  then  irrigated  and  repacked  loosely  with  gauze. 
Many  physicians  make  the  mistake  of  putting  the  dressings  in  too 
tightly,  thereby  arresting  granulation.  Patients  should  be  told  that 
they  have  a  serious  trouble  which  may  result  in  fistula  and  a  second 
operation,  though  this  is  rarely  necessary  when  the  abscess  has  been 
treated  properly,  and  by  that  is  meant  radically. 

Gonorrhoea  of  the  rectum  is  of  occasional  occurrence  in  America, 
but  more  frequent  in  England,  and  particularly  in  France.  It  is  caused 
by  infection  of  the  rectum  with  the  gonococcus  of  Neisser,  although, 
as  ordinarily  found,  it  is  here,  as  elsewhere,  a  mixed  infection.  It  is 
generally  caused  by  an  associated  attack  of  gonorrhoea  infecting  pri- 


INFECTIONS   OP   THE   RECTUM  827 

marily  the  genito-urinary  ajoparatus.  The  discharge,  which  is  generally 
copious  in  the  acute  stages,  may  bathe  the  perineum  or  invade  the  anal 
folds,  from  which  it  gains  ready  access  to  the  mucous  surfaces  above 
the  anal  constriction.  In  other  instances,  and,  perhaps,  in  the  majority 
of  all  instances,  the  infection  occurs  as  the  result  of  using  for  the  pur- 
pose of  a  rectal  injection  a  syringe  nozzle  which  has  been  employed  in 
an  infected  vagina.  The  disease  may  result  from  perverted  sexual 
indulgences. 

The  pathology  is  essentially  that  of  an  acute  inflammation  depend- 
ing for  its  occurrence,  primarily,  upon  the  specific  coccus  of  Neisser. 
The  action  of  this  micro-organism  is  very  virulent  and  results  speedily 
in  the  destruction  of  at  least  limited  areas  of  rectal  epithelium,  result- 
ing in  the  development  of  granular  patches  which  are  ordinarily  desig- 
nated ulcerations.  The  mucous  follicles  are  invaded,  resulting  in  their 
stimulation  to  catarrhal  activity.  If  the  epithelium  of  the  efferent 
ducts  is  destroyed,  they  may  become  occluded,  resulting  in  the  develop- 
ment of  retention  cysts.  The  majority  of  the  follicles,  however,  un- 
dergo hypertrophy  and  become  more  or  less  persistently  catarrhal.  In 
the  presence  of  an  infection  atrium,  the  micro-organisms  penetrate  the 
deeper  structures  and  may  cause  ischiorectal  abscesses;  or  they  may 
invade  the  lymph  spaces  causing  enlargement  of  the  pelvic  lymphatics, 
or  even  resulting  in  some  cases  in  suppuration.  The  infection  may,  by 
traversing  the  lymph  channels,  reach  the  peritoneum,  causing  septic 
inflammation  of  that  membrane.  When  the  inflammation  has  been  so 
intense  as  to  cause  extensive  epithelial  destruction,  post-inflammatory 
contractions  resulting  in  stricture  may  supervene. 

The  symptoms  of  gonorrhoea  of  the  rectum  consist  in  pain  asso- 
ciated with  burning  and  tenesmus  in  the  earlier  acute  stages;  there  is 
also  a  copious  muco-purulent  secretion  which  is  discharged  at  frequent 
intervals.  The  diagnosis  depends  upon  the  demonstration  by  means 
of  the  microscope  of  the  gonococcus  of  Neisser. 

Treatment  must  be  based  upon  the  facts  that  the  infection  is  a 
virulent  one  and  that  the  surface  of  the  rectum  is  very  absorbent. 
Antiseptic  agents,  such  as  carbolic  acid  or  the  mercuric  bichloride,  are 
not  eligible,  while  nitrate  of  silver  is  so  destructive  and  so  painful  that 
it  oiight  not  to  be  employed.  Strong  injections  of  saturated  solutions 
of  boric  acid,  however,  are  well  borne,  and  have  pronounced  antiseptic 
properties;  to  secure  their  best  effects,  however,  they  should  be  pre- 
ceded by  copious  injections  of  a  detergent  saline  solution,  such  as 
the  bicarbonate  of  sodium.  If  the  injections  are  given  cool,  they  will 
be  better  borne  and  have  a  soothing  effect  upon  the  inflamed  rectum. 
It  is  well,  in  some  cases,  to  begin  the  treatment  by  means  of  a  saline 
cathartic,  as  the  faecal  current  induced  by  that  means  will  wash  out 
much  of  the  infection;  and,  besides,  the  Bacilli  coli  communes,  which 
are  brought  down  in  large  numbers,  have  a  bactericidal  action  upon  the 
gonococci.  Topical  treatment  should  be  continued  until  the  gonococci 
can  no  longfu-  be  demonstrated  in  the  rectal  secretions. 


828  A   TEXT-BOOK  OF  GYNECOLOGY 

Syphilis  of  the  Rectum. — Syphilis  of  the  rectum  is  of  frequent  oc- 
currence, and  may  manifest  itself  at  any  stage  and  in  a  variety  of  forms. 
It  is  more  common  in  women  than  men  because  of  the  proximity  of 
the  anus  and  vulva.  The  inoculation  of  the  rectum  may  be  the  result 
of  syphilitic  discharges  coming  frqm  the  vagina  dribbling  over  the 
anus;  again  it  may  be  brought  about  by  a  chancre  on  the  penis  coming 
in  contact  with  the  anal  aperture  during  sexual  intercourse,  and  occa- 
sionally through  unnatural  copulation  (paederasty).  Chancroids  will 
be  considered  along  with  syphilis  because  it  is  often  difficult  to  distin- 
guish between  the  hard  and  soft  sores,  and,  further,  because  the  local 
treatment  of  these  two  affections  is  identical.  Syphilis  may  reveal  itself 
at  the  intestinal  extremity  in  the  congenital  variety  or  in  the  form  of 
a  chancre,  chancroid,  mucous  patch,  condylomata  or  gummatous  de- 
posit. 

In  congenital  syphilis  of  the  rectum,  the  anus  and  vulva  will  be 
disfigured  by  multiple  mucous  patches  and  irritating  fissures,  which 
cause  the  child  much  pain  when  a  hard  stool  is  passed.  Such  children 
have  notched  teeth  and  the  usual  characteristic  markings  of  inherited 
syphilis. 

True  chancre  of  the  rectum  is  uncommon,  but,  when  present,  its 
appearance  does  not  differ  greatly  from  that  of  chancre  elsewhere. 
There  is  but  one  ulcer,  surrounded  by  a  hard,  raised,  inflammatory  band, 
which  is  not  very  sensitive  to  the  touch,  and  does  not  give  much  pain 
unless  irritated.  It  is  sometimes  quite  difficult  to  distinguish  between 
it  and  a  chronic  fissure  or  ulcer,  and  for  that  reason  we  should  not 
be  hasty  in  making  our  diagnosis,  but  should  wait  for  the  eruption 
which  will  certainly  settle  the  question. 

Chancroids  at  the  anal  margin  are  quite  common,  especially  in  pros- 
titutes, but  cause  more  suffering  than  when  located  on  the  penis  or 
vulva,  which  fact  is  attributable  to  the  irritation  caused  by  the  passing 
over  them  of  the  fgeces.  They  are  usually  multiple,  superficial,  and 
have  sharply  defined  edges,  are  sensitive  to  the  touch,  and  give  off  a 
discharge  which  irritates  the  skin,  causing  a  pruritus  that  is  difficult  to 
relieve.  Now  and  then  they  extend  up  the  rectum  and,  when  healed,  a 
sufficient  amount  of  contraction  follows  to  produce  a  stricture.  They 
are  occasionally  seen  to  become  phagedenic  and  rapidly  eat  their  way 
into  adjoining  structures,  entirely  destroying  the  external  sphincter 
in  less  than  a  week's  time. 

Mucous  patches  are  disposed  to  form  at  the  anal  margin  during  the 
second  stage  of  syphilis.  They  are  moist,  slightly  elevated,  and  give 
off  a  foul  odour,  are  grayish  in  colour,  and  are  found  more  frequently 
in  this  locality  than,  perhaps,  any  other  manifestation  of  this  disease. 
When  the  parts  are  not  kept  clean,  they  multiply  swiftly  and  coalesce, 
forming  thick  warty  masses,  called  condylomata  (Fig.  339),  and  are 
covered  with  an  offensive  discharge  that  soon  inoculates  the  neigh- 
bouring skin  and  membrane;  in  fact,  if  allowed  to  run  an  uninterrupted 
course,  they  may  attain  enormous  proportions.    At  times,  these  masses 


INFECTIONS  OP  THE   RECTUM 


829 


will  be  separated  by  deep  fissures,  in  other  cases  they  degenerate  into 
a  low  form  of  ulceration. 

Gummata  are  not  seen  especially  frequently,  even  by  those  physi- 
cians who  do  a  large  practice  in  rectal  surgery;  at  the  same  time  they 
are  to  be  found  in  the  rectum  more  often  than  is  generally  believed 
by  the  profession,  and  with 
greater  frequency  in  this  lo- 
cality than  elsewhere  in  the 
intestine.  When  detected  early 
in  their  formation,  they  give 
to  the  finger  a  sensation  simi- 
lar to  that  of  an  abscess  before 
fluctuation  is  present;  in  other 
words,  they  feel  like  thick, 
flat,  indurated  masses  in  the 
rectal  wall.  After  they  break 
down,  the  rectum  feels  ragged 
to  the  touch  because  of  the 
nodules  and  intervening  ul- 
ceration. As  a  rule,  healing 
occurs  as  the  mass  gives  way, 
and  the  ulceration  extends  un- 
til sufficient  contractile  tissue 
is  formed  to  make  a  tight 
stricture.  Gummata  are  rare- 
ly numerous  and  large  enough 
to  obstruct  the  calibre  of  the 
bowel  to  any  serious  extent. 
Neither  do  they  cause  a  great 
deal  of  pain  by  pressure  upon 
the  nerves.  On  the  other 
hand,  when  a  stricture  has 
followed  their  breaking  down, 

the  suffering  of  such  patients  is  pitiable  to  behold,  they  spend  most 
of  their  time  in  the  closet  without  relief,  have  local  and  reflected  pains, 
itching  about  the  anus,  pass  large  quantities  of  pus,  blood,  and  mucus, 
and  frequently  suffer  from  abscess,  fistula,  and,  occasionally,  incon- 
tinence. 

Treatment. — Infants  suffering  from  congenital  syphilis  must  be 
put  through  a  course  of  treatment  early  in  their  career,  if  we  would 
rid  them  of  this  terrible  inheritance.  The  treatment  should  not  be 
ccmfined  to  the  child  alone,  the  mother  should  be  given  the  usual  anti- 
syphilitic  remerlies  diiring  the  nursing  period.  She  should  take  ten 
grains  of  the  iodide  of  potassium  three  times  daily,  a  short  time  before 
the  baby  is  permitted  to  be  nursed.  In  addition,  if  she  is  run  down, 
tonics  should  be  given  to  build  her  up.  The  child  should  be  given 
small  doses  of  tiK'i-cin-y,  pforcrably  in  ilu;  forin  of  an  ointment  rubbed 


j 

MM 

Hw^4 

ml 

'  3  4^ 

l^'l 

"':,     1 

^ ''■'?•■ 

J 

]?iHmii'j, 

Fig.  339. — "  They  multiply  swiftly  and  coalesce, 
forming  thick  warty  masses." — Gant  (page  828). 


830  A  TEXT-BOOK   OF  GYNECOLOGY 

in  over  the  abdomen  or  soles  of  the  feet.  For  the  local  manifestations 
about  the  anus,  cleanliness  is  the  principal  thing.  To  encourage  heal- 
ing, solutions  of  alum,  zinc,  lead,  or  the  bichloride  of  mercury,  or  pow- 
ders such  as  calomel,  iodoform,  orthoform,  subiodide  of  bismuth,  or 
tannic  acid,  judiciously  applied,  will  render  ef&cient  service. 

In  chancres  and  chancroids,  persons  suffering  from  the  former 
should  be  j)ut  through  the  ordinary  antisyphilitic  treatment.  The  local 
treatment  for  the  soft  and  hard  sores  is  practically  the  same.  They 
should  be  cleansed  several  times  a  day  with  antiseptic  and  stimulating 
solutions,  and  covered  with  a  reliable  ointment  or  powder  known  to 
have  healing  powers.  Sometimes  it  becomes  necessary  to  make  strong 
applications  to  them  of  the  nitrate  of  silver,  carbolic  or  nitric  acid,  or 
perhaps  the  actual  cautery;  the  latter  is  especially  valuable  where  they 
take  on  a  phagedenic  character. 

When  they  are  seen  in  the  early  stage,  mucous  patches  require 
the  same  treatment  as  the  chancre;  but  later  on,  when  they  have  pro- 
liferated and  formed  numerous  condylomatous  masses  upon  both  the 
skin  and  mucous  membrane,  they  require  radical  measures.  Gant 
excises  them  with  the  scissors  and  thoroughly  cauterizes  their  base  with 
the  Pacquelin  cautery,  and  then  treats  them  in  the  same  manner  as 
traumatic  ulceration.  They  are  so  persistent  that  even  this  operation 
may  have  to  be  repeated. 

Gummata  require  both  constitutional  and  local  treatment.  The 
iodide  of  potassium  in  large  doses  seems  to  prevent  the  formation  of 
new  deposits  and  to  hasten  the  absorption  of  those  present,  when 
accompanied  by  massage  of  the  rectum  by  means  of  the  Wales  rectal 
bougie.  Stricture  following  their  breaking  down  should  be  treated  as  a 
stricture  from  other  causes  similarly  located  (see  Stricture  of  the 
Eectum). 

Tuberculosis  of  the  Rectum. — The  rectum,  like  other  organs  of  the 
body,  is  occasionally  the  seat  of  tuberculosis;  here,  however,  suffering 
is  greater  and  healing  more  difficult  to  obtain  because  of  the  function 
of  this  organ.  It  is  interesting  to  note  the  proportion  of  persons  suffer- 
ing from  phthisis  who  are  subjects  of  anal  fistula  and  the  number  of 
the  latter  who  are  phthisical.  Probably  "  from  4  to  6  per  cent  of  all 
phthisical  patients  have  fistula,  while  a  much  larger  percentage  of 
those  afflicted  with  fistula  have  phthisis — 12  to  15  per  cent."  Koch 
holds  that  tuberculosis  of  the  intestine  may  be  primary,  or  secondary 
to  pulmonary  involvement.  The  bacilli  may  be  introduced  in  food, 
especially  milk,  or  through  the  swallowing  of  sputum  coming  from  a 
tuberculous  lung.  In  perfect  health,  tubercle  bacilli  are  destroyed  by 
the  gastric  juice,  but  in  cases  of  i^hthisis  where  there  is  a  lowered 
vitality  and  a  weakened  gastric  fluid,  it  is  believed  that  they  pass 
through  the  stomach  into  the  intestine  without  losing  their  activity. 
Earle  maintains  "  that  the  tuberculous  process  in  mucous  membranes, 
as  well  as  in  the  lungs,  can  advance  independently  of  the  formation  of 
miliary  tubercles."    He  also  reports  3  cases  of  primary  tuberculosis,  all 


INFECTIONS  OP  THE  RECTUM  831 

in  negroes.  He  says,  "  What  was  particularly  striking,  was  the  apparent 
acuteness  of  the  process;  the  mucous  membrane  between  the  points 
of  ulceration  was  swollen  and  injected;  in  some  cases  covered  with  a 
slight  fibrinous  exudation.  The  ulcers  appeared  to  result  from  the 
simple  breaking  down  of  this  swollen  and  injected  mucous  membrane." 
Gant  has  never  observed  the  condition  just  described.  On  the  con- 
trary he  has  often  seen  tuberculous  ulceration  of  the  rectum  where 
the  mucous  membrane  was  thin,  pale,  and  covered  with  a  thin  rice- 
coloured  discharge. 

Tuberculosis  manifests  itself  in  and  near  the  rectum  in  three  dif- 
ferent forms,  viz.,  ulceration,  stricture,  and  fistula. 

Ulceration. — From  a  clinical  standpoint  there  are  two  kinds  of 
tuberculous  ulceration  about  the  rectum,  neither  of  which  is  of  com- 
mon occurrence,  but  both  are  difficult  to  cure.  One  is  a  real  tuber- 
culosis and  can  be  demonstrated  by  the  presence  of  the  little  tubercles 
and  the  bacilli.  The  second  is  a  simple  ulceration,  from  whatever  cause, 
which  is  persistent  owing  to  the  debilitated  condition  of  the  patient 
caused  by  tuberculosis  in  the  lung. 

In  many  cases  of  tuberculosis  of  the  rectum,  the  disease  is  not  con- 
fined to  this  organ,  but  distributes  itself  along  the  entire  intestinal 
tract,  and  the  breaking  down  of  the  deposit  in  one  locality  is  followed 
shortly  by  a  similar  process  in  other  parts,  until  the  field  of  ulceration 
covers  a  considerable  portion  of  the  gut.  In  such  cases,  the  prog- 
nosis is  bad;  on  the  other  hand,  when  the  disease  is  located  in  the 
anal  region,  we  stand  a  fair  chance  of  efi'ecting  a  radical  cure,  if  we 
resort  to  heroic  measures. 

Tuberculous  stricture  is  a  rare  disease  in  the  rectum  because  the 
tendency  of  ulceration  is  to  extend  rather  than  to  heal  and  form  con- 
tractile tissue.  Gant  has  observed  in  young  women  2  cases  of  tight  stric- 
ture undoubtedly  of  tuberculous  origin.  There  are  also  two  kinds  of 
tuberculous  fistulce,  the  one  the  result  of  tuberculous  infection,  and  the 
other  due  to  ordinary  causes,  but  made  more  difficult  to  combat  because 
of  the  run-down  condition  of  the  patient,  occasioned  by  tuberculosis 
in  other  organs. 

Symptoms. — The  general  appearance  of  patients  suffering  from  the 
different  forms  of  tuberculosis  of  the  rectum  is  about  the  same.  They 
are  usually  much  debilitated,  have  a  sallow  complexion,  pinched  face, 
sunken  cheeks,  prominent  ears,  clubbed  nails,  absence  of  fat  in  the 
ischiorectal  fossa,  and  patulous .  anus  surrounded  by  abundant  long 
silky  hairs.  Many  have  an  ugly  cough  and  occasional  hemorrhages, 
and  are  bothered  with  annoying  night  sweats.  An  ulceration,  fistula, 
or  stricture  of  tuberculous  origin,  bleeds  less  and  is  freer  from  pain  than 
a  similar  condition  from  other  causes.  The  mucous  membrane  is  pale 
and  thin,  and  the  discharge  from  the  diseased  area  is  profuse,  watery, 
and  rice-coloured.  Fistulous  openings,  instead  of  being  small  as  in 
the  ordinary  fistula,  are  large,  irregular  in  shape,  bluish  around  the 
edges,  and  droop  into  the  opening  because  of  the  undermined   skin. 


832  A  TEXT-BOOK  OP  GYNECOLOGY 

A  probe  can  be  inserted  along  the  sinus  without  pain  or  difficulty. 
Those  accustomed  to  treating  rectal  diseases  have  little  trouble  in 
distinguishing  between  the  ordinary  and  the  tuberculous  types  of 
fistula. 

Treatment. — In  spite  of  our  best  efforts,  a  good  percentage  of  per- 
sons afflicted  with  tuberculosis  of  the  rectum  will  die  in  from  six 
months  to  three  years.  The  results  of  treatment  are  not  so  good  in 
this  ]ocality,  because  the  disease  is  being  constantly  aggravated  by  the 
passage  over  it  of  fa?ces.  The  most  essential  thing  in  the  treatment 
is  to  see  that  these  sufferers  get  a  reasonable  amount  of  exercise  in 
the  sunshine,  and  are  not  confined  in  bed  in  a  dark  room.  In  fact, 
we  should  make  everything  about  them  as  cheerful  as  possible.  Every 
means  should  be  resorted  to,  to  build  them  up;  generally,  for  this  pur- 
]3ose,  there  is  nothing  better  than  plenty  of  nourishing  food,  stimulants, 
and  tonics,  such  as  creosote,  guaiacol,  cod-liver  oil,  malt  extracts,  iron 
occasionally,  and,  in  fact,  any  tissue  builder.  If  they  can  afford  it, 
nothing  will  do  them  more  good  than  a  trip  to  the  seaside  or  a  change 
of  altitude.  Intestinal  antiseptics  should  be  given,  as  they  sometimes 
benefit  these  patients  very  much;  at  other  times,  however,  they  are 
worthless.  Ulceration  rarely  yields  to  palliative  treatment,  though  we 
have  to  rely  on  it  now  and  then  when  operation  is  refused.  The  ulcers 
should  be  cleansed  frequently,  after  which  some  stimulating  or  anti- 
septic solution  or  powder  should  be  applied.  If  they  have  a  tendency 
to  spread,  a  thorough  burning  with  nitric  or  carbolic  acid  becomes 
necessary.  A^^ien  the  treatment  of  tuberculosis  is  left  entirely  in  Gant's 
hands,  he  treats  it  as  though  it  was  malignant.  He  curettes  and  trims 
the  edges  of  the  ulcers;  after  this,  the  affected  area  is  thoroughly  cau- 
terized with  a  Pacquelin  cautery.  The  post-operative  treatment  is  the 
same  as  for  a  granulating  wound  of  the  rectum  from  other  causes.  Tu- 
berculous fistula?  should  be  laid  open  and  all  diseased  tissue  removed, 
and  should  then  be  cauterized  as  though  it  were  an  ulceration.  Care 
should  be  used  not  to  sever  the  sphincter  more  than  once,  for  incon- 
tinence occasionally  follows  the  operation.  If  it  is  thought  best  not 
to  give  a  general  ana?sthetic,  to  lose  much  blood,  or  to  put  the  patient 
to  bed,  a  ligature  may  be  passed  through  the  sinus  and  brought  out 
at  the  anus,  where  it  is  tied  and  allowed  to  cut  its  way  out.  A  cure  will 
sometimes  follow  this  method.  Tuberculous  stricture  requires  prac- 
tically the  same  treatment  as  a  constriction  in  the  rectum  from  other 
causes.  In  the  majority  of  cases,  however,  nothing  short  of  colostomy 
and  the  prevention  of  faecal  irritation  will  do  any  good.  After  this 
operation  a  radical  improvement  will  follow. 

Surgical  conditions  resulting  from  infections  of  the  rectum  are 
various.  Those  which  will  be  considered  in  this  connection  are  (a) 
anal  ulcer  or  fissure;  (6)  ulceration  of  the  rectum;  (c)  fistula;  {d) 
stricture. 

Anal  Ulcer  or  Fissure. — Salient  Symptoms. — Often,  there  is  itching 
at  the  anus.     Pain  on  defecation  or  immediately  thereafter  is  charac- 


INFECTIONS  OF   THE   RECTUM  833 

teristic.  Intolerably  painful  anal  spasm  is  often  present.  This  dis- 
ease sometimes  afEords  a  multiplicity  of  reflected  symptoms. 

Diagnosis. — Anoscopy  reveals  a  narrow  gray  or  red  erosion  or 
ulceration  lying  between  the  pilasters.  Careful  and  systematic  digi- 
tal eversion  of  the  anal  folds,  at  the  time  when  the  patient  bears 
down,  may  disclose  the  lesion.  When  the  point  of  the  probe  comes  in 
contact  with  the  fissure,  the  patient  usually  signifies  that  the  lesion 
is  discovered.  Fissures  are  most  commonly  situated  posteriorly  but 
may  be  situated  at  any  point  in  the  anal  circumference. 

A  hypertrophied  bit  of  tissue  of  a  pale  gray  colour,  and  of  about 
the  size  of  a  pin  head,  is  often  noticeable  at  the  lower  end  of  the  fis- 
sure; this  is  the  thickened  wall  of  the  anal  pocket,  to  which  Ball  has 
given  the  name  of  sentinel  pile. 

Treatment. — The  ulcer,  if  superficial,  is  to  be  touched  with  caustic 
or  the  electric  cautery.  This  treatment  is  to  be  repeated  after  inter- 
vals of  several  days.  It  may  be  alternated  with,  or  replaced  by,  the 
application  of  ointment,  stimulating  or  sedative  according  to  the  re- 
quirements of  the  ulcer.  A  convenient  method  of  applying  the  oint- 
ment is  shown  in  the  obturator-applicator  (Fig.  337). 

This  may  be  done  by  placing  the  ointment  in  the  cup,  as  shown 
in  the  illustration,  lubricating  the  distal  end  of  the  instrument  with 
the  ointment,  and  introducing  the  anoscope  to  the  necessary  depth. 
This  manoeuvre  places  the  ointment  at  a  point  opposite  the  diseased 
area  where  the  obturator  is  to  be  steadied  while  the  anoscope  is 
drawn  ofi^  it.  The  anus  clasps  the  applicator  around  the  anointed 
neck.  Gentle  rotation  and  withdrawal  of  the  instrument  expands  the 
anus  and  exposes  the  otherwise  infolded  and  concealed  diseased  area, 
and  rubs  into  its  surface  the  medicament  which  the  grasping  anus 
completely  strips  from  the  obturator.  Application  of  nitrate  of  silver 
solution  is  efficacious. 

The  simplest  and  most  efficacious  treatment  in  that  form  of  fissure 
that  undermines  the  integument  at  its  inferior  end,  consists  in  splitting 
the  pocket  by  means  of  a  small  scalpel  under  infiltration  anesthesia 
by  means  of  eucaine  or  nirvanine  solution.  The  hypertrophied  tissue 
should  be  trimmed  away.  The  ulcer  should  then  be  touched  with  a 
solution  of  nitrate  of  silver,  40  grains  to  the  ounce,  and  an  opium  sup- 
pository introduced.  The  anus  should  be  subsequently  dilated  twice 
daily  and  the  wound  kept  open  till  perfectly  healed.  Semidaily  im- 
mersion of  the  hips  in  hot  water  should  be  practised.  The  conven- 
tional operation  for  fissure  which  requires  general  anaesthesia,  divul- 
sion  of  the  sphincters,  and  their  division  by  incision,  is  haphazard 
surgery  and  not  uniformly  curative,  mutilates  an  important  organ, 
is  hazardous  to  its  functions,  and,  in  a  measure,  dangerous  to  the  life 
of  the  pationi:. 

Ulceration  of  the  Rectum. — Salient  8ym.ptoms. — There  is  usually 
steady  ficliing  or  scnsaiion  of  heat  and  weight  in  the  sacral  region 
anrl  liiMihMr  spine;  tlio  disease  is  initiated  with  a  short  period  of  obsti- 
54 


834 


A  TEXT-BOOK   OF  GYNECOLOGY 


pation  or  constipation,  sometimes  followed  by  a  somewhat  longer 
period  of  diarrhoea;  finally,  there  are  discharges  of  mucus.  The 
feces  are  sometimes  streaked  with  mucus,  with  patches  of  membrane, 
and  with  specks  of  blood,  and  there  is  always  more  or  less  purulent 
material  discernible.  Pain  and  soreness  are  not  uniformly  present 
when  the  disease  is  situated  high  up  in  the  rectum,  but  are  invariably 
present  when  it  is  situated  near  or  at  the  anus. 

Diagnosis. — Proctoscopy  reveals  the  fact  that  the  mucous  mem- 
brane lining  the  rectal  chambers  is  deeply  injected.  The  arborescent 
arterioles  may  appear  in  clusters  of  bright  red  twigs.  The  club-shaped 
venous  radicles,  which  are  of  a  purple  colour,  may  be  observed  some- 
what elevated  above  the  surface  of  the  mucous  membrane  at  various 
points  throughout  the  chambers,  and  there  is  a  generally  diffused  red- 
ness throughout  the  entire  area  involved.  Extensive  proctitis  some- 
times prevents  inflation  of  the  rectum.  This  may  be  overcome  by 
spraying  the  rectum  with  a  4-per-cent  solution  of  cocaine,  which 
causes  an  ischemia,  thins  the  wall  of  the  organ,  and  renders  it  inflat- 
able or  dilatable  by  the  use  of  the  coactor.  The  ulceration  is  charac- 
terized by  the  destruction  of  a  circumscribed  area  of  epithelium  occu- 
pied by  reddish  granulation  tissue;  the  surface  is  often  seen  coated 
with  inspissated  muco-pus.  Ulceration  may  be  accompanied  by  a 
more  or  less  diffused  chronic  proctitis  with  general  superficial  erosion 
of  the  mucous  membrane.  Venereal  ulcers  present  their  typical  fea- 
tures when  situated  in  this  organ.  Tuberculous  ulceration  presents 
a  clearly  defined  border  and  is  usually  surrounded  by  a  pale  blue 
mucous  membrane.  Microscopic  examination  of  scrapings  positively 
determines  its  character. 

Treatment. — Inflammation  and  ulcerations  of  the  rectal  mucous 
membrane  may  be  rapidly  cured  by  spraying  the  part  with  silver- 
nitrate  solutions  of  3  or 
4  grains  to  the  ounce. 
With  the  patient  under 
proctoscopic  examination, 
the  operator  should  take 
the  proctoscope  in  his  left 
hand,  and  in  his  right, 
the  anal  atomizer  which 
should  be  attached  to  a 
compressed-air  reservoir. 
By  co-ordinate  movement 
of  the  hands,  each  of 
the  chambers  involved  in 
the  disease  may  be  rap- 
idly and  systematically 
sprayed  with  the  solution  (Fig.  340).  If  the  hand-bulb  spray  is  used,  an 
assistant  will  be  required  to  hold  and  direct  the  proctoscope  from 
chamber  to  chamber. 


Fig.  3-iO. — "Each  of  the  chambers  involved  in  the  dis- 
ease may  be  rapidly  and  systematically  sprayed." — 
Maktin. 


INFECTIONS  OF   THE  RECTUM  835 

Because  of  the  humidity  of  the  rectum,  the  actual  cautery  should 
not  be  introduced  into  it  as  the  consequent  rapid  evaporation  occa- 
sions intense  pain.  Chancroid  ulcers  should  be  coated  once  with  the 
charcoal-and-sulphuric-acid  paste.  Enemas  of  bovinine  prove  decid- 
edly reparative.     Rectal  lavage  should  be  employed  daily. 

Fistula. — Salient  Symptoms. — Muco-purulent  discharges  from  the 
rectum,  or  sero-purulent  discharges  from  an  opening  in  the  adjacent 
anal  surface,  are  the  common  manifestations  of  this  disease. 

Diagnosis. — With  the  patient  in  the  Sims  posture,  manual  eversion 
of  the  buttocks  should  be  practised  while  the  patient  is  required  to 
bear  down.  At  this  moment,  ocular  inspection  of  the  field  should 
be  made.  Crypts,  lacuna,  or  other  depressions  of  the  surface,  should 
be  critically  examined  with  the  point  of  the  probe.  .Should  the 
probe  enter,  the  patient  should  be  required  to  relax  the  parts,  and 
a  tentative  search  should  be  made  for  the  internal  orifice  of  the  fis- 
tula. The  probe  should  be  steadied  and  the  patient  put  into  Martin's 
posture,  which  usually  smooths  out  the  intra-anal  folds  of  membrane, 
and  the  anoscope  introduced,  and,  by  means  of  another  probe,  in- 
spection should  then  be  made  of  the  mucous  surface  of  the  anus  to 
determine  if  there  is  an  internal  orifice.  The  internal  orifice  of  a 
fistula  discharging  internally  is  usually  marked  by  small  granulations 
or  vegetations.  The  search  may  be  made  more  thorough  if  a  small 
applicator  is  employed  to  smooth  out  intra-anal  folds  of  mucous  mem- 
brane. The  sphincters  should  be  cocainized  and  a  fenestrated  conoid 
speculum,  such  as  Aloe's,  inserted  on  its  obturator,  and  the  obturator 
or  slide  withdrawn.  This  instrument  should  be  introduced  with  its 
fenestrum  straddling  the  tissues  penetrated  by  the  first  probe.  Care- 
ful search  for  an  internal  orifice  should  be  repeated.  If  none  is  dis- 
covered, the  probe  should  be  withdrawn  and  the  cavity  of  the  fistula 
injected,  at  its  external  orifice,  with  a  sterile  solution  of  milk  or  per- 
oxide of  hydrogen  and  the  anoscopy  repeated.  If  even  this  manip- 
ulation fails  to  discover  an  internal  orifice,  further  search  should  be 
abandoned  till  the  time  of  operation. 

Treatment. — The  probe  should  be  introduced  into  the  external 
orifice  of  the  fistula,  the  conoid  speculum  reintroduced,  and  its  fenes- 
trum made  to  straddle  the  probe  as  already  described.  The  tissue 
from  the  external  orifice  of  the  fistula  to  a  point  within  the  anus  as 
bigh  as  the  distal  end  of  the  probe,  should  be  subjected  to  infiltration 
anaBsthesia.  The  probe  should  be  thrust  onward  through  the  mucoiis 
membrane  and  into  the  channel  of  the  gut.  An  incision  should  be 
made  through  both  mucous  and  cutaneous  surfaces  down  to  the  probe. 
If,  on  the  other  hanrl,  the  fistula  has  an  internal,  but  no  external  open- 
ing, the  probe  should  be  bent  to  form  a  long  hook-end  and  should  be 
carried  through  the  anoscope  or  Aloe's  speculum,  and  into  the  in- 
terna] orifice.  When  it  has  been  made  to  pass  as  deeply  toward  the 
cutaneous  surface  as  possible,  the  anoscope  should  be  withdrawn  and 
an  effort  made  to  draw  tlio  prob(!-hook  deeper  tbrough   the  relaxed 


g3<3  A  TEXT-BOOK   OF  GYNECOLOGY 

tissues  and  toward  the  skin.  The  probe  should  be  steadily  maintained 
in  this  position  while  the  fenestrated  conoid  speculum  is  made  to 
straddle  it.  Infiltration  anaesthesia  should  be  established,  and  an 
incision  made  in  the  manner  already  described.  The  wound  should  be 
antiseptically  dressed  and  cared  for.  The  more  radical  operation,  con- 
sisting in  dissecting  out  the  sac  and  suturing  together  the  freshened 
surfaces  of  the  walls  of  the  fistula,  may  be  performed  under  local 
anaesthesia.  This  operation  begins  where  the  simpler  procedure  just 
described  leaves  off,  inasmuch  as  that  technique  is  necessary  to  expose 
the  fibrous  structure  of  the  fistula  wall.  Bleeding  vessels  should  be 
clamped  and  hot  gauze  pads  applied  to  the  wound  till  all  hemorrhage 
is  checked,  for  a  bloodless  field  is  necessary  for  infiltration  anaes- 
thesia. The  hemorrhage  stopped,  the  anesthetic  solution  should  be 
injected  all  about  the  fibrous  tissue  to  be  removed,  the  most  accessible 
portions  should  be  seized  with  a  hemostat  for  convenience  of  manipu- 
lation, and  a  rapid  dissection  made.  An  assistant  must  follow  each 
sweep  of  the  knife  with  the  hot  gauze,  for  anaesthesia  and  a  non- 
bleeding  field  go  hand  in  hand.  The  fibrous  tissue  should  not  be  re- 
moved piecemeal;  the  portion  dissected  loose  may  be  used  as  a  re- 
tractor to  facilitate  the  dissection  of  that  still  attached.  The  parts, 
fascia,  sphincter  and  other  muscle,  and  integuments,  should  be  re-an- 
nesthetized  and  the  wound  closed  by  suture.  Fistul^e  located  laterally 
and  anteriorly  to  the  anus,  and  having  an  external  orifice,  if  the  recto- 
vaginal^ septum  is  not  divided,  take  a  course  forward  into  the  labium 
majus,  or  backward  toward  the  anterolateral  anal  quadrants,  which 
they  tend  to  enter  between  the  sjDhincters.  Fistulfe  situated  in  the 
ischiorectal  fossae  usually  penetrate  the  rectum  on  the  side  of  their 
origin  and  between  the  sphincters.  If  they  enter  the  body  farther, 
they  generally  take  an  outward  direction  beneath  the  levator  ani  or 
cocc5'geus  muscle.  External  fistulae  are  not  often  situated  posteriorly. 
But,  not  infrequently,  a  complete  internal  fistula  may  be  discovered 
by  means  of  the  diagnostic  technique  described,  situated  posteriorly, 
and  having  an  inferior  orifice  at  the  border  of  the  internal  sphincter 
and  a  superior  orifice  posteriorly  and  above  the  coccygeo-levator  ani. 
When  the  probe  has  entered  an  inch  (2.54  centimetres)  or  more,  a 
fenestrated  curette  should  be  introduced  into  the  rectum  to  a  point 


Fig.  341. — The  valvotome. — Martin  (page  837). 


higher  than  the  estimated  site  of  the  end  of  the  probe,  and  an  endeav- 
our made  to  hang  the  curette  thereon.  If  this  succeeds,  and  the 
curette  can  not  be  directly  withdrawn,  the  diagnosis  of  the  complete 


IXFECTIOXS   OF   THE   RECTUM 


837 


fistula  just  described  is  made.  A  grooved  director  should  be  substi- 
tuted for  the  probe,  a  3-inch  needle  fixed  to  the  hypodermic  syringe, 
and  the  tissue  between  the  director  and  the  rectal  lumen  infiltrated 
with  the  anaesthetic;  then  the  special  knife  shown  in  Fig.  341  may 
be  put  into  the  director  and 
made  to  cut  through  the  ano- 
rectal wall.  When  this  is  ac- 
complished, the  director  and 
curette  may  be  withcbawn 
without  removing  the  former 
from  the  f enestnim  of  the  lat- 
ter. The  fibrous  base  of  the 
fistula  should  now  be  curetted 
and  subsequently  packed. 
Daily  anal  dilatation  should 
be  enjoined  till  the  wound 
heals.  Simple  external  fis- 
tulas of  recent  origin  may  be 
cured  by  curettage,  by  injec- 
tion of  stimulating  fluids,  and 
by  vigilant  general  care. 

Abscesses  and  fistulte  in 
the  pelvic  floor  about  the 
anus,  often  present  the  most 
complex  problems.  Their  per- 
fect comprehension  involves 
a  study  of  the  faseise  of  the 
pelvic  floor. 

Stricture  of  the  rectum  is 
a  diminution  of  tlie  calibre  of 
the  bowel  from  any  cause. 
Usually  it  is  the  result  of  an 
ulceration  leaving  thickened 
walls  of  contractile  tissue 
(Fig.  342).  Tumours  within 
or  without  the  bowel  are  often 
responsible  for  this  affection; 
again,  it  may  be  the  result  of 
an  enlarged  prostate,  or  of  the 

pressing  of  the  rectum  back  upon  the  bony  structures  by  a  retroverted 
uterus.  In  exceptional  ca.ses,  it  is  due  to  fibrous  bands  extending  from 
one  side  of  the  bowel  to  the  other.  From  the  standpoint  of  physical 
exploration,  strictures  may  be  divided  into  three  classes:  viz.,  (a)  annu- 
lar or  narrow;  (h)  tubular  or  broad,  and  (c)  nodular.  In  the  first,  only  a 
small  portion  of  the  bowel  is  involved;  in  the  second,  the  strictured 
area  may  occupy  several  inches;  while  in  the  third,  the  obstruction 
is  the  result  of  one  or  more  nodular  tumours   projecting   into   the 


Fig.  ?A-2 


-••  Ulceration  leaving  thickened  walls  of 
contractile  tissue."' — Gaxt. 


838  A  TEXT-BOOK  OF  GYNECOLOGY 

calibre  of  the  bowel  at  one  or  more  points.  Again,  strictures  are 
further  divided,  and  are  called  complete  when  there  is  total  obstruction, 
and  incomplete  when  all  or  a  part  of  the  faeces  escape  through  them. 
Congenital  strictures  will  not  be  dealt  with  here.  From  a  pathological 
standjaoint,  Gant  classifies  strictures  of  the  rectum  as  follows: 

(1)  Traumatic;  (2)  syphilitic;  (3)  tuberculous;  (4)  catarrhal; 
(5)   dysenteric;   (6)   malignant. 

(1)  Traumatic. — All  agree  that  traumatism  is  a  frequent  cause  of 
stricture  of  the  rectum.  It  may  be  the  result  of  any  one  of  a  number 
of  operations  performed  about  the  rectum  and  anus  for  the  relief  of 
hemorrhoids,  fissure,  ulceration,  fistula,  prolapse,  or  cancer.  It  is 
sometimes  caused  by  direct  injury  to  the  rectum  as  the  result  of  an 
accident,  or  the  swallowing  of  some  hard  substance,  as  a  piece  of  bone 
or  a  pin,  which  lodges  near  the  anus  and  keeps  up  a  constant  irrita- 
tion. The  most  frequent  cause  of  traumatic  stricture  is  constipation 
and  impaction.  Chronic  constipation,  where  the  faeces  are  allowed  to 
remain  in  the  bowel  for  several  days  at  a  time,  is  a  frequent  cause 
of  stricture.  (2)  Syphilis  may  be  the  cause  of  stricture  of  the  rectum 
as  a  resiilt  of  chancres  or  chancroidal  ulceration  in  the  initial  stage, 
of  gummatous  deposits,  or  of  extensive  ulceration  following  the  break- 
ing down  of  such  deposits,  the  latter  being  by  far  the  more  frequent 
cause.  Syphilis  probably  causes  as  many  strictures  as  all  the  other 
etiological  factors  put  together.  (3)  T uhfrculosis  of  the  rectum  sel- 
dom causes  stricture,  because,  when  the  tubercles  begin  to  give  way, 
they  can  only  exceptionally  be  successfully  healed,  in  consequence 
of  the  absence  of  contractile  tissue.  Gant  has  seen  cases  of  marked 
constriction,  however,  that  could  not  be  attributed  to  other  causes, 
(■i)  Chronic  catarrhal  inflammation  of  the  rectum  may  result  in  stric- 
ture as  the  result  of  occlusion  brought  about  by  the  inflammatory 
thickening  of  the  bowel,  or  from  an  ulceration  started  and  maintained 
by  the  presence  of  large  quantities  of  irritating  mucus.  (5)  Dysen- 
teric stricture  is  rarely  seen  in  this  section  of  the  country,  because 
here  we  have  dysentery  only  in  a  mild  form,  but  in  tropical  countries, 
where  it  is  common  in  the  severe  form,  it  frequently  results  in  a  light 
stricture.  (6)  Stricture  due  to  cancer  is  found  as  often  in  the  rec- 
tum, as  in  all  other  parts  of  the  intestines.  It  may  be  the  result  of 
one  or  more  large  hard  masses  obstructing  the  calibre  of  the  bowel, 
or  be  due  to  cicatrization  following  ulcerations  when  they  break  down, 
or  to  both  these  causes. 

The  symptoms  of  stricture  may  be  local  or  constitutional,  depend- 
ent upon  the  condition  at  the  time  of  observation;  if  extensive  ulcera- 
tion is  present  and  the  obstruction  is  complete,  the  usual  symptoms 
of  the  accumulation  of  pus  and  obstruction  will  be  present.  The 
symptoms  usually  met  with  in  a  bad  case  of  stricture  are,  constipation  at 
the  beginning;  diarrhoea,  intermitting  with  constipation;  intense 
straining;  a  sensation  as  though  the  bowel  never  completely  emptied 
itself;  slight  rise  in  temperature;  occasional  chill;  indigestion;  mild 


INFECTIONS   OF   THE   RECTUM 


839 


peritonitis;  tympanites;  usually  loss  in  weight;  incontinence;  dis- 
charges of  pus,  blood  and  mucus;  pain  in  the  rectum  and  distant 
parts ;  change  in  size  and  character  of  the  faeces ;  numerous  long  slen- 
der skin  tags,  and  partial  or  complete  obstruction. 

Diagnosis. — A  large  majority  of  rectal  strictures  are  located  in  the 
lower  3  inches  of  the  bowel  and  are  easily  recognised.  When  in  the 
upper  part,  if  they  can  not  be  located  by  the  aid  of  bougies  and  the 
colon  tube,  an  ansesthetic  should  be  given,  the  abdomen  opened,  and 
the  gut  pulled  up  and  examined. 

Treatment. — The  treatment  is  (a)  palliative,  and  (b)  operative. 
(a)  Palliative  measures  for  the  relief  of  stricture  consist  in  keeping 
the  stricture  open  and  hastening  absorption;  softening  the  fgeces  that 
they  may  pass  through  it ;  alleviating  pain,  and  protecting  the  system 
against  the  absorption  of  poisons  contained  in  the  rectum  because 
of  the  pus  and  retained  faeces.  Iodide  of  potassium  in  increasing 
doses  and  the  massage  of  the  stricture  with  the  fingers  or  soft  bougies, 
do  a  great  deal  of  good  in  the 
earlier  stages;  but  when  the 
constriction  is  composed  of 
contractile  tissue  the  results 
are  not  so  good.  The  diet 
should  be  restricted,  so  far  as 
possible,  to  fluid  and  semi- 
solid foods,  and  to  those 
which  leave  little  residue. 
Pain  is  best  alleviated  by 
keeping  the  rectum  clean 
with  astringent,  stimulating, 
or  antiseptic  solutions;  when 
faecal  masses  accumulate 
above  the  stricture,  mild 
laxatives  should  be  used,  and 
high  enemata  of  water,  soap- 
suds, or  oil  and  glycerine,  but 
strong  purgatives  should 
never  be  given.  In  order 
patient  may  get 
at  night,  opium, 
chloral,  or  the 
intelligently     ad- 


that    the 
some    rest 
morphine, 
bj'omides. 


Fig.  343. — ^"The  calibre  of  a  stricture  may  be  ma- 
terially  increased   by    means   of  gradual   .   . 
divulsion." — Gant  (page  840). 

ministered,  will  do  as  well  as 

any  other  drugs;  but  they  must  be  given  with  caution,  for  this  affec- 
tion is  chronic,  and  many  of  these  sufferers  readily  fall  into  the  habit 
of  taking  them  to  ease  their  pain. 

(b)  Operaiive. — In  spite  of  the  best  palliative  treatment,  most  stric- 
tures gradually  progress  until  partial  or  complete  obstruction  is  pres- 
ent, anrl  it  is  rie(;essnry  to  resort  to  ;iti  operation  to  give  them  tempo- 


g40  A  TEXT-BOOK   OF   GYNECOLOGY 

rary  or  permanent  relief.  Enthusiasts  in  the  use  of  electricity  main- 
tain, that,  by  this  means,  they  can  destroy  the  stricture  or  cause  it  to  be 
absorbed.  Gant,  however,  from  what  he  has  seen,  is  inclined  to  doubt 
the  accuracy  of  this  claim. 

The  following  are  the  most  favoured  surgical  procedures  for  the 
relief  of  stricture  of  the  rectum,  viz. :  1,  dilatation ;  3,  internal  proc- 
totomy; 3,  external  proctotomy;  4,  excision;  5,  colostomy. 

The  calibre  of  a  stricture  may  be  materially  increased  by  means  of 
gradual  (Fig.  343)  or  forcible  divulsion.  The  first  is  accomplished 
gradually  by  the  passage  of  graduated  soft-rubber  bougies ;  steel  in- 
struments should  not  be  used  because  of  the  danger  of  rupturing  the 
bowel.  Bougies  should  be  used  two  or  three  times  each  week  until 
relief  is  obtained.  If  the  patient  will  give  her  consent,  forcible  divul- 
sion is  preferable,  because,  under  general  anaesthesia,  we  can  accom- 
plish with  the  fingers  in  five  minutes  what  would  otherwise  take 
weeks.  Strictures  of  more  than  3^  inches  should  not  be  divulsed  un- 
less every  precaution  has  been  taken,  for  if  the  bowel  is  ruptured,  the 
rectal  contents  are  dumped  into  the  peritoneal  cavity  and  death  will 
shortl^v  result. 

Inter  tied  proctotomy  is  done  by  guiding  a  blunt-pointed  bistoury 
with  the  index  finger  until  it  is  above  the  point  of  constriction,  when 
the  latter  is  severed  at  one  or  more  points  as  the  case  demands.  A 
piece  of  gauze  is  then  placed  in  the  incisions,  to  be  changed  from  time 
to  time,  and  the  rectum  cleansed  as  after  any  other  wound  in  it. 

External  (or  complete)  proctotomy  is  performed  by  carrying  the 
knife  above  the  stricture,  as  in  the  internal  method;  it  is  then  pointed 
backward  until  the  bony  structures  are  reached,  when  it  is  brought 
down  and  out,  dividing  the  stricture  and  other  tissues  including  both 
sphincters,  thus  leaving  a  long,  deep,  triangular  cut.  The  advantages 
of  this  operation  over  the  one  Just  described,  are  several;  it  permits 
of  free  drainage,  bleeding  can  easily  be  detected  and  arrested,  it 
allows  the  free  exit  of  accumulated  faeces,  and  admits  of  medication, 
at  all  times,  both  below  and  above  the  strictured  area.  When  a  stric- 
ture involves  only  the  superficial  structures  of  the  rectum,  is  freely 
movable,  and  is  situated  near  the  anus,  excision  is  justifiable.  When 
ulceration  is  extensive  and  obstruction  is  threatened,  colostomy  should 
be  insisted  upon,  for  it  is  the  only  thing  that  offers  any  permanent 
relief  from  the  never-ending  desire  to  stool.  Frequently,  after  this 
operation,  patients  gain  flesh  and  return  to  their  work  feeling  like 
new  beings.  This  operation  is  described  in  the  chapter  on  Malignant 
Growths  of  the  Eectum. 


CHAPTER    LII 

NEOPLASMS   OF   THE   RECTUM   AND  ANUS 

Adenoma — Lipoma — Fibroma — Papilloma — Angeioma — Teratoma  (dermoid  cysts) 
— Retention  cysts — Myoma  and  enchondroma — Malignant  growths,  symptoms, 
treatment — Operations :  Divulsion ;  internal  proctotomy ;  posterior  proctot- 
omy ;  curettage ;  colostomy ;  excision — Hemorrhoids,  causes :  External,  symp- 
toms, treatment :  Internal,  symptoms,  treatment — Operations  :  Injection  ; 
Whitehead's;  ligature;  clamp  and  cautery. 

The  rectum  and  anus  are  the  seat  of  new  growths  as  frequently  as 
other  parts.  Some  writers  labour  under  the  mistaken  idea  that  ma- 
lignant tumours  and  simple  polypi  are  about  the  only  neoplasms  to 
be  found  in  this  locality.  Gant  does  not  deny  that  they  are  of  fre- 
quent occurrence,  but  there  are  a  variety  of  other  growths  which  mani- 
fest themselves  in  the  rectum  with  varying  frequency.  Any  of  the  fol- 
lowing-named tumours  are  likely  to  be  met  with  by  physicians  having 
a  large  rectal  following:  (1)  adenoma  (polypus);  (2)  lipoma;  (3) 
fibroma;  (-i)  papilloma;  (5)  angeioma;  (6)  teratoma  (dermoid 
cysts);  (7)  retention  cysts ;  (8)  myoma;  (9)  enchondroma;  (10) 
malignant  growths;   (11)  varicose  tumours  (hemorrhoids). 

Adenoma  (Polypus). — Adenomata  are  found  more  frequently  in  the 
rectum  than  in  any  other  part  of  the  intestinal  canal.  In  fact  they 
occur  there  with  greater  regularity  than  almost  any  other  tumour. 
Benign  or  simple  adenomata  are  common  in  childhood,  and  com- 
paratively rare  in  adults,  unless  preceded  by  some  other  disease  with 
a  coincident  discharge.  On  the  other  hand,  malignant  adenomata  usu- 
ally attack  those  past  middle  life,  and  are  rarely  seen  in  children. 
All  rectal  tumours  have  a  tendency  to  become  pedunculated,  because 
'they  are  dragged  down  daily  by  the  faeces.  The  word  polypus  is  com- 
monly applied  to  any  growth  in  this  locality  having  a  narrow  or 
pedunculated  laminar  attachment,  with  a  large  movable  pendulous  ex- 
tremity. Van  Buren  once  said  that  "in  proportion  as  a  tumour  becomes 
pedunculated  its  danger  of  being  malignant  lessens."  Gant's  experi- 
ence has  been  in  accord  with  Van  Buren's.  ISTevertheless,  it  is  at  times 
diflicult  to  flistinguish  between  the  benign  and  malignant  forms  of 
adenoma.  There  are  two  kinds  of  polypi,  the  adenoid,  or  soft  (Fig. 
344),  and  the  fibrous,  or  hard  (Fig.  345).  In  rare  instances,  either  of 
these  growths  may  be  found  in  great  numbers  scattered  over  the  en- 
tire rectal  mucosa;  they  are  then  distinguished  as  disseminated  polypi. 

841 


842 


A   TEXT-BOOK  OF  GYNECOLOGY 


Symptoms. — Polypi  vary  in  size  from  that  of  a  pea  to  that  of  an 
English  walnut.  The  symptoms  depend  largely  upon  the  size,  loca- 
tion, number,  and  condition,  of  the  tumours  when  seen.  When  situ- 
ated high  up  in  the  rectum  or  sigmoid,  they  manifest  their  presence 
by  irritating  the  mucous  membrane,  causing  a  sensation  of  uneasiness 
and  the  discharge  of  considerable  mucus.     Occasionally,  they  cause 


Fig.  344. — "  The  adenoid  or  soft  polypus."- 
Gant  (page  841). 


Fig.  345.- 


■  The  fibrous  or  hard  polypus."- 
Gant  (page  841). 


invagination,  tenesmus,  and  straining.  If  ulcerated,  they  bleed,  and, 
when  located  near  the  anus,  they  protrude  during  stool.  As  a  rule, 
they  cause  little  pain  unless  strangulated. 

Treatment. — Ordinary  polypi  are  easily  cured  when  within  reach. 
They  may  be  clamped  with  Gant's  clamp,  cut  off,  and  the  stump  thor- 
oughly cauterized  with  the  Pacquelin  cautery.  When  a  cautery  is  not 
available,  ligature  and  excision  will  prove  quite  as  effective,  but  will 
cause  more  pain.  When  small,  they  may  be  seized  with  forceps  and  ^ 
twisted  off;  when  high  up  in  the  rectum,  the  snare  is  sometimes  serv- 
iceable; Gant  prefers  in  such  cases  to  seize  the  growth  with  a  long- 
handled  clamp  forceps  and  allow  it  to  remain  in  situ  until  it  comes 
off  of  its  own  accord.  Medication  in  these  cases  will  prove  unsatis- 
factory. Once  in  a  while  polypi  come  away  spontaneously  or  are 
detached  by  faecal  accumulations. 

Lipoma. — Fatty  tumours  are  occasionally  met  with  in  the  anal 
region  and  do  not  differ  in  their  construction  from  that  of  similar 
tumours  in  other  localities.  Gant  has  seen  them  both  in  the  circumrectal 
tissues  and  under  the  skin  at  the  anal  margin.  One  tumour  on  the 
buttock  at  the  verge  of  the  anus  was  quite  as  large  as  a  goose's  egg. 


NEOPLASMS  OP   THE  RECTUM  AND  ANUS 


843 


Treatment. — The  treatment  consists  in  their  enucleation  and  the 
closure  of  the  wound  with  catgut. 

Fibroma. — In  rare  instances  fibromata  develop  about  the  anus 
and  vulva,  and  in  the  rectal  wall,  without  becoming  pedunculated. 
They  then  present  themselves 
in  the  form  of  hard,  smooth 
tumours  (Pig.  346).  They 
resemble  fibromata  of  the 
cutaneous  surface  in  every 
way,  except  that  they  are  cov- 
ered by  mucous  membrane. 

Papilloma.  —  Papillomata 
are  not  uncommon  in  this  re- 
gion because  of  the  irritation 
of  the  parts  by  the  faeces  and 
infectious  discharges  coming 
from  the  vagina.  Senn  has 
frequently  seen  the  rectum 
studded  with  papillary  tu- 
mours varying  in  size  from 
that  of  a  hemjD-seed  to  that 
of  a  cherry.  They  are  to  be 
seen  on  the  skin  about  the 
anus  just  about  as  frequently 
as  upon  the  mucous  mem- 
brane. As  before  intimated, 
they  may  be  the  result  of 
a  syphilitic,  chancroidal,  or 
gonorrhoeal  infection,  or  they 
may  reveal  themselves  with- 
out any  previous  discoverable 
irritation.  When  located  in- 
side the  rectum  they  are  ac- 
companied by  occasional  hemorrhages,  the  discharge  of  mucus,  and 
tenesmus;  when  upon  the  skin,  by  smarting,  soreness,  and  a  foul  odour 
when  multiple  and  in  clusters. 

Treatment. — Palliative  measures  are  now  and  then  effective. 
These  consist  in  cleanliness,  cauterization  with  acids,  carbolic  and 
nitric,  or  the  application  of  astringent  powders,  as  tannic  and  gallic 
acid,  aluiii,  zinc,  or  calomel.  The  radical  method  of  cutting  them  off 
with  scissors  and  cauterizing  the  stumps  with  the  actual  cautery  is  the 
most  satisfactory  way  of  dealing  with  them. 

Angeioma. — A  few  cases  of  angeioma  (nsevus)  of  the  rectum  have 
bo(!n  recorded.  Gant  has  never  seen  what  he  considers  a  typical  case, 
though  he  has  met  with  vascular  growths  which  bled  freely  from  vari- 
ous points.  They  were  flat  tumours,  located  about  3  inches  above  the 
anus. 


Fig.  346. — "  In  rare  instances  fibromata  develop 
about  the  anus  and  vulva  and  in  the  rectal 
wall." — Gant. 


84^  A   TEXT-BOOK  OF  GYNECOLOGY 

Treatment. — They  should  be  extirpated  by  ligation  or  cut  away 
with  scissors,  the  bleeding  being  arrested  with  the  Pacquelin  cautery. 

Teratoma  (Dermoid  Cysts). — Dermoid  cysts  containing  hair  and 
sometimes  teeth  are  not  at  all  uncommon  in  the  sacral  region,  and  are 
frequently  the  exciting  cause  of  fistula.  Now  and  then  they  are  found 
in  the  rectal  wall  and  the  hairs  may  be  seen  projecting  into  the  rectum 
or  out  at  the  anus.  They  vary  in  size  from  that  of  a  cherry  to  that  of 
an  apple.  Their  symptoms  and  management  in  this  locality  are  the 
same  as  in  other  parts;   the  safest  treatment  is  complete  removal. 

Retention  Cysts. — Eetention  cysts  filled  with  secretions  and  excre- 
tions, which  may  or  may  not  have  undergone  degeneration,  are  at  times 
found  in  and  outside  the  rectum.  They  occasionally  reach  enormous 
proportions,  Gant  having  removed  one  8  inches  in  circumference.  In 
one  case,  they  may  be  filled  with  firm  sebaceous  material,  in  another, 
with  a  fairly  thick  whitish  fluid.  They  cause  no  discomfort  further 
than  a  fulness  of  the  part  affected. 

Treatment. — The  entire  cyst  wall  should  be  carefully  dissected  out 
and  the  wound  united  with  catgut,  otherwise  the  cyst  will  refill. 

Myoma  and  Enchondroma. — New  growths  composed  of  muscular 
and  cartilaginous  structures  have  been  found  in  the  rectum.  The 
former  is  of  more  frequent  occurrence  than  the  latter,  and  is  found 
in  that  situation  with  greater  frequency  than  in  other  parts  of  the 
intestine.  Nothing  short  of  removal  should  be  considered  for 
their  relief. 

Malignant  Growths. — There  is  still  doubt  as  regards  the  true  cause 
of  malignant  tumours.  Statistics,  however,  show  that  they  are  on 
the  increase  in  the  rectum  as  well  as  in  other  organs.  This  does 
not  apply  to  the  negro  race,  as  negroes  are  practically  immune  to  this 
disease.  Because  of  its  function  and  make-up,  the  rectum  is  the  seat 
of  about  80  per  cent  of  all  morbid  growths  occurring  in  the  intes- 
tines. Malignancy  is  common  in  middle  life,  less  so  in  old  age,  and 
rarer  still  in  childhood.  The  prognosis  is,  as  a  rule,  bad,  few  living 
more  than  a  year  after  the  disease  is  recognised.  In  exceptional 
cases^  however,  patients  may  live  two,  three,  and  even  four  years.  The 
younger  the  person,  the  sooner  death  will  ensue.  Malignant  growths 
of  the  rectum  develop  principally  from  glandular  tissue,  and  are 
grouped  by  Cripps  {Rectal  Cancer,  third  edition,  p.  56)  under  the  one 
head  of  adenocarcinoma.  Sarcoma  is  extremely  rare  in  this  region,  but 
Gant  operated  on  a  case  of  fibrosarcoma  with  multiple  fistula  involv- 
ing the  rectum  and  anus  (Fig.  347).  Carcinomata  may  manifest 
themselves  as  flat  tumours  in  the  rectal  wall,  may  project  into  the 
lumen  of  the  bowel,  or  circumscribe  the  lumen  by  a  nodular 
band.  Because  of  this  difference  in  their  clinical  appearance.  Cooper 
and  Edwards  (Diseases  of  the  Eectvm  and  Anns,  p.  190)  have  de- 
scribed them  as  laminar,  tuberous,  and  annular.  Squamous-celled 
carcinoma  (epithelioma)  is  occasionally  met  with  at  the  mucocuta- 
neous margin. 


NEOPLASMS   OF   THE   RECTUM   AND  ANUS 


845 


Symptoms. — In  the  earlier  stages  of  rectal  cancer,  patients  do  not 
complain  of  acute  pain,  but  of  sensations  of  uneasiness,  weight,  and 
fulness  in  the  bowel.  When  the  tumour  grows  to  considerable  pro- 
portions and  breaks  down  leaving  a  large  ulcerated  area,  the  following 
symptoms  will  be  present : 

(1)  Irregular  or  constant  pains  in  the  rectujn,  neighbouring  or- 
gans, and  back  of  and  down  the  limbs;  (2)  typical  cachectic  waxy 
complexion;  (3)  tape  or  ribbonlike  stools;  (4)  prolonged  straining 
and  a  never-ending  desire  to  empty  the  bowel;  (5)  abundant  dis- 
charges of  blood,  pus,  and  mucus;  (6)  loss  of  flesh;  (7)  because  of 
increased  peristalsis,  food  is  rushed  through  the  alimentary  canal  un- 
digested;    (8)    constipation   intermitting   with   diarrhoea;     (9)    low 


Fig.  347.— "A  case  of  fibrosarcoma  with  multii^le  tistulfe  involving  the  rectum  and  anus." 

— Gant  (page  844). 


form  of  peritonitis;  (10)  obstruction  partial  or  complete ;  (11)  when 
the  growth  is  located  at  the  verge  of  the  anus,  pain  is  much  more 
severe  owing  to  sphincteric  contraction;  (12)  in  the  majority  of  cases 
there  is  partial  or  complete  incontinence. 

Treatment. — The  treatment  of  malignant  tumours  of  the  rectum  is 
unsatisfactory  because  most  patients  die  in  spite  of  anything  that 
can  be  clone.  While  Gant  does  not  feel  justified  in  stating  that  this 
disease  is  incurable,  he  does  believe  that  total  extirpation  results  more 
often  in  failure  than  its  advocates  would  have  the  profession  believe. 
Medication  is  useless  beyond  the  relief  it  offers  from  pain,  in  the 
liquefaction  of  the  faeces,  and  as  a  disinfectant  in  the  various  solu- 
tions used  Tor  iiiigating  purposes.  The  diet  should  be  regulated  and 
these  sufferers  slnndd  have  plenty  of  sunshine  and  strengthening  food. 


846  A    TEXT-BOOK  OF  GYNECOLOGY 

Operations. — The  following  operations  have  been  suggested  for  the 
relief  of  cancer  of  the  rectum :  ( 1 )  Divulsion,  rapid,  with  the  fingers, 
or  gradual  with  bougies;  (3)  internal  proctotomy;  (3)  posterior  proc- 
totomy; (4)  curettage  and  cauterization;  (5)  colostomy  (Ailing- 
ham);  (6)  excision.  The  operations  to  be  described  should,  with  the 
exception  of  excision,  be  regarded  as  palliative  measures  only,  and  those 
who  hope  to  make  a  radical  cure  with  them  will  be  disappointed. 

Divulsion. — Sometimes  there  are  patients  suffering  from  new 
growths  at  the  anus  and  low  down  in  the  rectum,  who  are  threatened 
with  obstruction,  and  are  constantly  annoyed  by  straining  in  their 
endeavour  to  relieve  the  bowel,  who  yet  refuse  to  let  the  knife  be  used. 
In  such  cases,  it  is  justifiable  to  resort  to  stretching  the  rectum,  either 
wdth  the  fingers  or  bougies  as  may  be  deemed  best  (Fig.  3-il),  and 
temporary  relief  will  follow,  because  the  fseces  escape  and  the  rectum 
can  be  irrigated. 

Internal  proctotomy  consists  in  passing  a  probe-pointed  bistoury 
beyond  the  point  of  constriction  and  incising  the  stricture  or  growth 
one,  two,  three,  or  as  many  times  as  becomes  necessary,  to  relieve 
the  obstruction.  As  a  rule,  the  wound  soon  heals,  contraction  follows, 
and  the  operation  requires  to  be  repeated. 

Posterior  proctotomy  is,  next  to  colostomy,  the  best  of  all  the 
palliative  operative  procedures.  It  is  performed  as  follows :  Protect 
the  knife  with  the  finger  and  pass  it  well  above  the  obstruction,  then 
directly  backward  to  the  bony  structures,  and  thence  downward,  carry- 
ing it  through  the  rectum  and  sphincters,  until  the  cut  is  on  a  level 
with  the  tip  of  the  coccyx,  thus  making  a  long  deep  triangular  wound 
that  gives  plenty  of  room  for  the  escape  of  accumulated  faeces  and  at 
the  same  time  permits  free  drainage,  a  great  advantage  over  the  inter- 
nal method.  Post-operative  treatment  consists  in  topical  applications 
to  the  ulceration,  and  the  occasional  passage  of  a  bougie  to  prevent 
rapid  contraction. 

Curettage. — Persons  suffering  from  that  form  of  malignant  growth 
in  which  numerous  cauliflowerlike  masses  project  into  the  rectum, 
inducing  pain  and  the  frequent  discharge  of  pus  and  blood,  can  fre- 
quently be  relieved  by  scraping  them  down  to  a  level  with  the  rectal 
wall,  and  then  burning  the  raw  surface  thoroughly  with  the  actual 
cautery.  The  operation  should  be  repeated  as  soon  as  the  growth 
returns. 

Colostomy  is  the  most  satisfactory  measure  we  have  for  the  relief 
of  rectal  cancer,  and  we  do  not  except  excision,  taking  one  case  with 
another.  It  diminishes  the  patient's  suffering  because  it  permits  a 
free  exit  to  the  fascal  matter  above  the  diseased  part,  thereby  doing 
away  with  the  diarrha3a  and  straining.  It  permits  free  irrigation  of 
the  rectum.  Many  patients  soon  regain  the  flesh  they  had  lost  and,  in 
fact,  feel  like  new  beings;  and  they  are  not  constantly  annoyed  by  the 
escape  of  faeces  through  the  artificial  anus  as  some  writers  have  stated. 
The  lumbar  opening  has  been  discarded  for  the  inguinal  (Fig.  348), 


NEOPLASMS  OF  THE  RECTUM  AND  ANUS 


847 


principally  because  the  patient  can  take  care  of  herself  after  the  latter. 
The  most  important  point  in  the  operation  is  to  make  a  good  spur, 
so  that,  when  the  gut  external  to  the  skin  is  removed,  the  ends  of  the 


Fig.  348. — "The  lumbar  opening  has  been  discarded  for  the  inguinal." — Gant  (page  846j. 

intestines  will  remain  parallel,  thus  insuring  that  the  faeces  shall  be 
deposited  on  the  outside  and  not  escape  into  the  rectum  as  is  the  case 
when  this  precaution  is  not  taken.  A  procidentia  may  ensue  (Fig. 
349)  when  the 
mesentery  is  too 
long,  in  which 
case  several 
inches  of  the  in- 
testine should  be 
cut  off  to  prevent 
this  accident. 

Excision. — 
Some  writers  af- 
firm that  by  ex- 
tirpation of  the 
growth  they  can 
effect  a  perma- 
nent   cure    in     a  Fig.  349. — "  A  procidentia  may  ensue." — Gabtt. 

large    percentage 

of  their  cases;  such  claims  are  just  the  opposite  of  the  experience  of 
those  surgeons  that  confine  their  practice  to  diseases  of  the  rectum. 
Gant  does  not  say  that  life  is  not  materially  prolonged  by  this  operation, 


848 


A  TEXT-BOOK  OF   GYNECOLOGY 


but  he  does  believe^  however,  that  the  patients  radically  cured  in  this 
way  are  few  indeed;  it  has  been  his  experience  that  the  growth  soon  re- 
turns. Excision  is  all  right  in  properly  selected  cases,  but,  in  most  in- 
stances, the  surgeon  does  not  see  the  patients  until  the  disease  is  far 
advanced.  A  gro\\i;h  situated  near  the  anus  can  usually  be  removed  by 
making  a  posterior  incision  as  far  back  as  the  coccyx.  After  the  coccyx 
is  removed,  sufficient  room  will  be  obtained  to  enable  the  operator  to 
free  the  rectum  from  its  attachments,  this  being  best  done  with  the  fin- 
ger or  a  jjair  of  blunt  scissors.  The  growth  is  then  cut  away,  leaving  the 
sphincter  if  possible,  and  the  distal  and  proximal  ends  united;  when 
there  is  too  much  tension,  bleeding  should  be  arrested  and  the  bowel 
allowed  to  retract.  If  the  peritoneum  has  been  opened,  it  should  be 
closed  with  catgut  sutures  or  protected  with  sterile  gauze  and  let  alone. 
Bougies  should  be  passed  biweekly  to  prevent  too  much  contraction. 
The  high  excision,  or  Kraska  method,  consists  in  removing  a  portion 
of  the  sacrum  for  additional  room,  and  the  suturing  of  the  gut  into 
the  upper  end  of  the  wound  when  it  can  not  be  brought  down  and 
united  to  the  severed  gut  below.  The  chief  advantage  claimed  for  this 
operation  is  that  it  gives  sufficient  room  for  the  surgeon  to  remove  the 


Fig.  850.^"  Eecurring  adenocarcinoma  about  the  sacral  anus  following  Kraska's 
operation." — Gant. 


entire  growth.    However,  Gant  had  a  case  of  recurring  adenocarcinoma 
about  the  sacral  anus  following  Kraska's  operation  (Fig.  350). 

Hemorrhoids  differ  so  widely  in  location,  appearance,  and  make-up, 
that  it  is  impossible  to  give  a  satisfactory  definition  of  them.  In  a 
general  way  we  might  define  them  as  being  vascular  tumours  of  the 
mucous  membrane  of  the  rectum,  the  anus,  or  both.  They  may  be  external 
or  internal;   the  former  are  covered  by  integument,  and  the  latter  by 


NEOPLASMS  OP   TFIE   RECTUM   AND  ANUS 


849 


mucous  membrane.     Tumours  covered  in  part  by  skin  and  in  part 
by  membrane  are  known  as  combination  piles. 

Causes. — The  larger  rectal  veins  pass  through  the  rectal  wall  by 
means  of  little  slits  (Fig.  351).  Verneuil  believes  the  return  flow  of 
venous  blood  is  impeded  by  the  contraction  of  the  muscular  fibres 
around  them,  and,  for  this  reason,  he  thinks  that  these  little  button- 
holes are  an  important  factor 
in  the  causation  of  hemor- 
rhoids. We  believe  this  to  be 
in  a  measure  true,  but  there 
are  other  factors  that  play  a 
much  more  important  part; 
because  of  gravitation,  and 
the  fact  that  the  rectal  veins 
have  no  valves,  the  erect  pos- 
ture assumed  by  man  has  a 
great  deal  to  do  in  the  pro- 
duction of  enlarged  veins. 
Again  the  fasces,  by  the  time 
they  reach  the  rectum,  are 
solid,  and  frequently  cause 
venous  obstruction.  Certain 
obstructive  diseases  of  the 
heart  and  liver,  a  retroverted 
uterus,  stricture  of  the  rectum 
or  urethra,  chronic  diarrhoea, 
overpurgation,  stone  in  the 
bladder,  or  anything  that 
presses  upon  the  veins,  are 
causes ;  frequent  and  pro- 
longed straining  will,  sooner 
or  later,  produce  hemorrhoids. 
Many  cases  can  be  traced  di- 
rectly to  irregularities  in  liv- 
ing.    In  fact,  anything  that 

forces  an  abnormal  amount  of  blood  into  the  rectum,  or  interferes  with 
its  return  therefrom,  may  be  regarded  as  a  cause. 

External  Hemorrhoids. — There  are  two  kinds  of  external  piles;  when 
composed  of  hypertrophied  folds  of  skin,  they  are  called  cutaneous, 
when  filled  with  a  firm  dark  clot,  thrombotic.  The  former  are  usually 
cbronic  and  are  the  colour  of  the  skin,  the  latter  come  on  suddenly, 
have  a  bluish  tint,  and  look  like  a  bullet  beneath  the  skin. 

Symptoms. — Under  favourable  circumstances  they  produce  a  sen- 
sation of  fulness  about  tlie  anus.  When  inflamed,  a  smarting  is 
felt,  and  when  relief  is  not  to  be  had,  the  sphincter  becomes  irri- 
table and  the  suffering  is  materially  increased  by  its  frequent  con- 
traction. 


Fig.  351. — "  The  larger  rectal  veins  pass  through 
the  rectal  walls  by  means  of  little  slits." — Gant. 


850  A  TEXT-BOOK  OF  aYNECOLOGY 

Treatment. — In  so  far  as  the  palliative  treatment  is  concerned,  both 
varieties  of  external  piles  should  be  treated  alike.  The  diet  should 
be  restricted  to  fluids  and  semisolids,  and  if  this  does  not  suflice,  a 
laxative  should  be  given.  For  this  Gant  prefers  Carabana  water,  2 
ounces  in  a  tumbler  of  warm  water  before  breakfast.  The  inflammation 
should  be  reduced  by  constant  application  of  hot  poultices,  cold  appli- 
cations, or  lotions  composed  of  lead,  zinc,  alum,  opium,  krameria,  or 
other  astringent  remedies.  When  the  suffering  is  sufficient  to  keep 
the  patient  awake,  relief  may  be  had  by  an  injection  of  one  fourth  of 
a  grain  of  morphine  sulphate.  To  allay  pain  and  soothe  the  sphincter 
muscle,  the  following  ointment,  which  the  patient  may  use  freely  both 
inside  and  outside  the  anus,  may  be  given: 

1$  Morphinse  sulphatis grana  vj  to  viij ; 

Calomel   grana  xij; 

Vaseline 5J- 

Sig.  Use  freely. 

An  ointment  composed  of  opium  and  belladonna  is  a  good  com- 
bination and  will  diminish  pain. 

Surgical  Treatment. — When  the  physician  has  the  election  of  the 
method  of  treatment  in  a  given  case,  he  should  not  waste  time  with 
palliative  measures,  but  should  relieve  the  patient  quickly  and  per- 
manently by  operation,  in  one  of  two  ways.  The  cutaneous  pile  should 
be  cut  off  with  the  scissors  and  the  edges  of  the  wound  brought  to- 
gether with  catgut  or  allowed  to  granulate.  The  tliromhotic  variety 
should  be  laid  open  with  a  bistoury,  the  clot  turned  out,  the  rent  in 
the  vessel  cauterized,  and  the  cavity  packed  with  gauze,  which  prevents 
hemorrhage  and  allows  the  blood  to  escape  in  case  bleeding  occurs.  A 
combination  pile  should  be  treated  as  the  internal  variety,  except  that 
the  incision  should  be  extended  to  include  some  of  the  adjoining  skin. 

Internal  Hemorrhoids. — There  are  two  varieties  of  internal  hemor- 
rhoids: capillary  and  renous.  The  former  are  supplied  principally  by 
the  superficial  vessels  of  the  mucous  membrane,  and  the  latter  by  the 
veins  of  the  mucous  and  submucous  tissues.  Capillary  piles  are  broad 
flat  tumours  that  bleed  readily  and  look  very  much  like  strawberries. 
Venous  piles  are  of  frequent  occurrence  and  are  composed  of  dilated 
veins.  They  may  be  small,  may  remain  within  the  bowel  and  bleed 
freely,  or  they  may  be  large  and  protruding,  and  may  bleed  occasionally 
(Fig.  353). 

The  symptoms  of  hemorrhoids  vary  according  to  the  duration,  kind, 
and  violence  of  the  attack.  The  following  are  some  of  the  more  com- 
mon symptoms  subject  to  the  above  conditions:  (1)  Protrusion  all  or 
a  part  of  the  time.  (3)  Bleeding  varying  from  a  few  drops  to  a  pro- 
fuse hemorrhage.  (3)  A  sensation  in  the  rectum  as  if  there  was  some- 
thing in  the  bowel  that  ought  to  come  away.  (4)  Pain,  intermittent 
and  slight,  or  excruciating  and  constant,  according  to  the  amount  of 
inflammation,  ulceration  and  strangulation.     (5)   Spasmodic  contrac- 


NEOPLASMS  OF  THE  RECTUM  AND  ANUS 


851 


tion  of  the  anal  sphincters.  (6)  Extreme  nervousness  and  loss  of  flesh. 
(7)  When  piles  are  ulcerated,  there  is  more  or  less  pruritus  caused  by 
the  discharge.  (8)  When  strangulation  continues  for  several  days,  it 
causes  constipation  and  a  slight  rise  of  the  temperature. 

Treatment:  Palliative. — Correct  errors  in  diet,  keep  the  faeces  soft, 
and  return  all  protruding  tumours  when  seen  before  strangulation 
has  begun,  for  once  they  are 
caught  outside  the  anus  no  at- 
tempt at  reduction  should  be 
made,  because  the  irritable 
sphincter  would  immediately 
throw  them  out  again.  The 
re«iedies  suggested  in  the  treat- 
ment of  external  hemorrhoids 
for  the  relief  of  pain  and  in- 
flammation can  be  successfully 
employed  in  the  treatment  of 
internal  hemorrhoids.  When 
there  is  bleeding,  it  becomes 
necessary  to  inject  astringent 
solutions  into  the  rectum  and, 
by  means  of  a  speculum,  to 
apply  styptics  directly  to  the 
ulcers.  This  procedure  will  re- 
quire several  days,  and  the  pa- 
tient will  suffer  considerable 
pain  before  piles  that  are  stran- 
gulated •  can  be  relieved,  and 
patients  should  be  made  to  un- 
derstand this  from  the  start. 

Surgical. — Many  authorities 
discountenance  operation  on 
piles  that  are  strangulated,  ul- 
cerated, or  inflamed,  until  after 

the  reduction  of  the  tumours  and  inflammation  and  the  healing  of  the 
ulceration.  Gant  advises  an  operation  irrespective  of  their  condition, 
so  soon  as  the  patient's  consent  can  be  obtained,  for  the  reason  that 
she  will  be  about  after  a  radical  operation  in  a  shorter  time  than  it 
takes  to  reduce  the  inflammation.  Many  operations  have  been  devised 
for  the  cure  of  hemorrhoids,  but  the  injection,  Whitehead's,  the  ligature, 
and  the  clamp-and-cautery  methods,  are  the  only  procedures  worthy  of 
spec'al  consiflecation. 

Injection. — This  method  was  the  rage  ten.  years  ago;  to-day,  it  is 
resorted  to  only  in  carefully  selected  cases.  Any  one  who  is  foolish 
enough  to  attempt  to  cure  all  piles,  irrespective  of  location  or  condi- 
tion, by  injecting  tbem,  will  be  sadly  disappointed.  He  will  not 
only  fail  to  cure  his  patients,  but  will  cause  them  much  unnecessary 


Fig.  352. — "They  may  be  large  and  protrud- 
ing, and  may  bleed  occasionally." — Gant 
(page  850). 


852  A  TEXT-BOOK   OF  GYNECOLOGY 

suffering  and  a  greater  loss  of  time  than  if  they  had  had  the  clamp- 
and-cautery  or  ligature  operation  performed.  This  method  of  treating 
piles  apjjeals  to  the  patients  because  they  do  not  have  to  take  an  an- 
aesthetic, submit  to  the  knife,  and  suffer  pain,  and  they  are  not  pre- 
vented from  following  their  occupations.  This  is  true  in  successful 
cases;  but  in  others,  their  suffering  is  excruciating,  because  of  slough- 
ing, ulceration,  abscess,  or  fistula,  and  they  fail  to  be  cured  after  all 
they  have  gone  through.  If  only  small  pendulous  piles,  situated  well 
above  the  grasp  of  the  external  sphincter,  are  injected,  the  results 
will  be  gratifying.  Many  solutions  have  been  brought  forward,  but 
only  those  containing  carbolic  acid  deserve  commendation.  This  drug 
has  been  used  successfully  in  combination  with  distilled  water,  glyc- 
erine, and  olive  oil,  varying  in  strength  from  4  to  75  per  cent.  Yount 
prefers  the  weaker,  and  Agnew  the  stronger,  solution.  Gant  uses  the 
following  mixture: 

I^  Carbolic  acid 3j ; 

Glycerine,  )  ^^   '^-: 

^.'',.„      '    ,        y aa  oi. 

Distilled  water,  j 

M.  Sig.  Inject  from  5  to  10  drops  in  small,  and  from  10  to  15  in 
large  piles,  and  see  that  they  are  pushed  out  of  reach  of  the  sphincter. 

Whitehead's  Operation. — This  operation  consists  in  detaching  the 
mucous  membrane  from  the  skin  and  dissecting  it  from  the  submucosa 
until  the  upper  part  of  the  pile-bearing  area  is  reached;  it  is  then 
amputated  and  the  distal  end  brought  down  and  sutured  to  the  skin 
with  silk  sutures,  which  are  allowed  to  cut  their  way  out.  Whitehead 
says  that  it  is  the  most  natural  method,  requires  few  instruments  and 
little  dexterity,  and  that  there  is  less  pain,  and  danger  of  secondary 
hemorrhage  from  it  than  after  either  the  ligature  or  the  clamp-and- 
cautery  operations.  The  operation  is  radical,  but  Gant's  experience 
bears  him  out  in  saying  that  it  is  difficult  and  bloody,  and  requires 
more  instruments,  a  longer  time  to  perform,  and  causes  more  pain 
owing  to  tension,  than  either  the  clamp-and-cautery  or  the  ligature. 
Because  of  tension  and  the  danger  of  infection,  nonunion  is  common. 
As  a  result,  the  portion  of  the  bowel  between  the  anus  and  the  retracted 
gut  is  uncovered  by  mucous  membrane,  leaving  a  broad  circular  ulcer- 
ated band  that  eventually  terminates  in  stricture,  incontinence,  and 
pruritus.  There  is  also  an  absence  of  the  normal  secretions  to  lubricate 
the  fgeces,  and  a  loss  of  sensibility  to  warn  the  patient  of  an  approach- 
ing stool.  When  primary  union  is  obtained,  these  patients  are  up  and 
about  in  two  weeks. 

Ligature. — Only  a  few  years  ago  nearly  all  the  prominent  surgeons 
of  this  country  were  doing  the  ligature  operation.  To-day,  the  clamp- 
and-cautery  ranks  equally  with  it  in  popularity,  and  in  a  few  years 
more  it  will  probably  be  the  operation  of  election  for  the  radical  cure 
of  piles.    Hippocrates  and  Celsus  used  the  ligature  by  simply  placing 


NEOPLASMS   OF   THE   RECTUM  AND   ANUS 


853 


Fill.  J.)  >  -  i;  M  Eicketts  uses  the  hgatuie  submu- 
cously,  beginning  at  the  muco-eutaneous  margin." 
— Gant. 


it  around  the  pile  and  allowing  it  to  slough  off.  Modern  surgeons  first 
make  an  incision  at  the  mucocutaneous  border  before  applying  the 
ligature,  in  order  that  the 
nerves  may  not  be  includ- 
ed, and  severe  afterpain 
may  be  thus  avoided.  The 
final  result  of  either  op- 
eration is  equally  good, 
for  both  effect  a  radical 
cure  in  a  much  shorter 
time,  and  with  fewer  com- 
plications and  less  incon- 
venience than  any  other 
operation.  B.  M.  Eick- 
etts  uses  the  ligature  sub- 
mucously,  beginning  at 
the  muco-cutaneous  mar- 
gin (Fig.  353).  The  liga- 
ture may  encircle  in  its 
sweep  the  bases  of  sev- 
eral tumours.  Then,  be- 
ing  brought   out   at    the 

point    of    original    insertion,    it    is    tied,    causing    subsequent    atro- 
phy and  disappearance  of  the  hemorrhoids   (Fig.   354). 

Clamp-and-Cautery. — 
This  operation,  as  com- 
pared with  the  ligature, 
is  comparatively  new,  yet 
it  has  been  given  sufficient 
trial  by  the  profession  to 
gain  for  itself  an  enviable 
reputation.  Gant  j^refers 
this  to  the  ligature  opera- 
tion because  after  it  there 
is  less  pain,  spasm  of  the 
sphincter,  and  bladder  dis- 
turbance, and  patients  are 
able  to  resume  their  oc- 
cupations m.ore  quickly. 
Hemorrhoids  can  be  re- 
moved just  as  quickly  with 
the  clamp-and-cautery  as 
with  the  ligature,  and 
there  is  just  as  much  dan- 
ger of  secondary  h(!morrhage  occurring  after  one  as  the  other  (Fig.  355). 
Before  he  flevis(!(]  liis  own  clamp  (Fig.  350)  Gant  had  a  serious  hemor- 
rhage after  tin's  operation,  due  to  an  imperfect  instrument  allowing 


Fui.  354.- 


-"  Being  brought  out  at  the  point  of  original 
innertion,  it  is  tied." — Gant. 


854 


A  TEXT-BOOK  OF  GYNECOLOGY 


a  part  of  the  stump  to  slip  through  the  clamp  after  the  tumour  had 
been  cut  away,  and  before  there  was  an  opportunity  to  cauterize  it. 
He  has  also  had  the  same  accident  because  of  a  ligature  slipping  dur- 
ing a  violent  attack  of  coughing.     Bleeding  does  not  occur  when 


Fig.  356. — "Hemorrhoids  can  be  removed  just  as  quickly  with  tlie  clamp-and-cautery  as  with, 
the  ligature." — Gant  (page  853). 

cauterization  is  properly  done;  the  tissues  should  be  thoroughly  burned 
with  the  cautery  at  a  red  heat,  and  the  clamp  loosened  and  read- 
justed if  there  is  any  bleeding.  G-ant  has  been  doing  this  operation 
constantly  for  the  past  ten  years  and  has  not  had  a  fatal  hemorrhage 

or  a  stricture  or  other 
accident  following  it. 
Mathews  says:  "I  use 
this  plan  (clamp-and- 
cautery)  in  selected 
cases,  viz.,  where  there 
is  a  large  amount  of  skin 
around  the  anus,  which 
is  embraced  in,  or  goes 
to  make  up,  a  part  of  the  internal  hemorrhoid.  If  this  amount  of  skin 
is  cut  off,  excessive  bleeding  may  occur.  If  an  incision  is  made  around 
it  and  it  is  ligated,  we  are  chary  about  cutting  too  close  to  the  liga- 
ture, and  therefore  we  have  much  skin  left  and  many  ligatures."    Gant's 


Fig.  356. — Gant's  clamp  (page  853). 


NEOPLASMS  OF  THE  RECTUM  AND  ANUS        855 

experience  has  been  the  opposite  of  tliis;  he  has  found  that  the  bleed- 
ing following  the  removal  of  piles  covered  by  skin  is  of  no  importance, 
and  is  easily  arrested  by  a  gauze  compress.  It  is  not  surprising  that 
patients  thus  operated  on  suffer  great  pain,  for  excruciating  pain  fol- 
lows the  cauterization  of  the  skin  in  any  part  of  the  body,  and  Gant 
never  removes  a  skin  pile  by  the  clamp-and-cautery  for  this  reason;  he 
does  operate  on  all  internal  hemorrhoids  in  this  way,  because  there  is 
so  little  post-operative  pain  when  the  cauterization  is  confined  to 
mucous  and  submucous  tissues.  Allingham  says:  "  My  most  careful 
researches  have  led  me  to  a  conclusion  that  it  (clamp-and-cautery)  is 
quite  six  times  as  fatal  as  the  ligature,  properly  and  dexterously  ap- 
plied." He  does  not,  however,  point  out  what  causes  these  fatalities, 
nor  does  he  give  statistics  to  substantiate  his  statement.  Gant  has 
never  known  of  a  i^erson  dying  from  this  operation,  nor  has  he  seen  such 
a  case  recorded  in  medical  journals.  No  doubt  there  are  cases  of 
death  from  this  cause  on  record,  but  the  same  can  be  said  of  the  ligature 
operation. 


CHAPTEE    LIII 

PELVIC   DISEASES  AND   NERVOUS   AFFECTIONS 

Coincidence  of  pelvic  and  nervous  diseases — Neurasthenia:  Symptoms,  conclusions 
— Hysteria :  Symptoms,  pathology,  conclusions — Operations  for  the  neuroses — 
Nervous  symptoms  of  pelvic  disorders. 

Coincidence  of  Pelvic  and  Nervous  Diseases. — It  has  been  thought 
wise  that  some  one  should  present  briefly  in  this  treatise,  from  the 
standpoint  of  the  neurologist,  the  essential  facts  in  regard  to  the 
nervous  affections  to  which  women  are  especially  liable.  As  is  well 
known,  pelvic  and  nervous  diseases  frequently  exist  concurrently  in 
the  same  patient.  This  fact  alone  makes  a  consideration  of  the  nerv- 
ous features  of  special  importance.  Besides,  the  advance  made  in  the 
study  of  functional  nervous  diseases  has  been  equally  great  with  that 
made  in  gynecology.  Views,  new  and  comprehensive,  now  throw  light 
upon  fields  where  formerly  there  was  only  darkness  and  confusion. 

Neurasthenia  is  one  of  the  two  great  neuroses  to  which  women  are 
especially  liable,  the  other  being  hysteria.  Too  often  the  physician 
turns  aside  from  the  subject  of  neurasthenia  as  uninteresting,  as 
being  a  term  applied  to  a  condition  rather  than  a  disease,  and  as  pre- 
senting symptoms  that  are  vague  and  ill  defined,  from  a  study  of 
which  nothing  definite  can  be  gained.  In  reality,  neurasthenia  is  an 
exceedingly  interesting  affection;  one  which,  far  from  displaying  a 
vague  and  ill-defined  symptomatology,  presents  a  symptom  group  as 
fixed  and  as  definite  as  that  of  any  disease  with  which  we  are  acquainted. 
It  is  true  that,  now  and  then,  the  symptoms  differ  widely  in  detail, 
but  they  always  present  the  same  essential  features.  They  are  always 
expressive  of  fatigue,  and  Dercum  has,  therefore,  proposed  for  neu- 
rasthenia the  far  more  expressive  name  of  the  fatigue  neurosis.  The 
stamp  of  fatigue  is  ineffaceably  fixed  upon  every  case.  Every  symp- 
tom is  expressive  of  weakness,  of  irritability,  and  of  ready  exhaustion. 
A  brief  glance  at  the  clinical  picture  will  bear  this  statement  out. 

The  symptoms  of  neurasthenia  resolve  themselves  into  sensory, 
motor,  general  somatic,  and  psychic  disturbances.  Most  of  them  are  the 
direct  result  of  chronic  overfatigue;  a  smaller  number  are  an  indirect 
result,  and  these  serve,  at  times,  to  complicate  the  picture.  Dercum 
has  separated  the  symptoms  into  two  great  groups:  first,  the  primary  or 
essential  symptoms  of  neurasthenia;  and,  secondly,  the  secondary  or 
adventitious  symptoms. 
856 


PELVIC   DISEASES  AND  NERVOUS  AFFECTIONS  857 

Beginning  with  the  sensory  symptoms  we  have,  first,  a  general 
sense  of  fatigue  or  tiredness.  This  may  be  diffused  throughout  the 
entire  body,  but  is  generally  accentuated  in  special  regions,  e.  g.,  the 
head,  the  back,  or  the  limbs.  It  is  characteristic  of  this  sense  of 
fatigue  that,  in  the  simple  and  typical  cases,  it  is  brought  on  if  absent, 
or  made  worse  if  present,  by  effort.  It  is  expressive  of  diminished 
power  for  the  sustained  expenditure  of  energy,  and  it  is  to  be  looked 
upon  as  one  of  the  primary  symptoms  of  neurasthenia.  The  sensation 
that  characterizes  it  is  one  of  generalized  distress  or  discomfort  diif used 
throughout  the  entire  body,  and  is  not  referred  to  any  particular  re- 
gion. In  this  respect,  it  closely  resembles  the  sensation  of  fatigue  that 
follows  prolonged  exertion  in  perfectly  healthy  persons.  However,  if 
the  conditions  causing  this  general  sense  of  tiredness  persist,  the  sensa- 
cion  ceases  to  be  merely  one  of  fatigue  and  becomes  one  of  pain.  In 
other  words,  when  fatigue  sensations  become  exaggerated,  they  become 
painful,  and  they  are  then  described  by  the  patient  as  aches  of  various 
kinds  and  are  referred  to  special  regions.  Very  commonly,  for  in- 
stance, the  patient  complains  of  headache.  When  present  in  a  mild 
degree,  this  headache  is  diffused,  and  is  described  as  -a  dull  feeling 
or  a  dull  aching,  and  is  then  relieved  by  the  mere  cessation  of  work,  that 
is,  by  rest.  When  it  is  more  pronounced,  it  becomes  accentuated  in 
certain  regions.  Thus,  it  is  referred  especially  to  the  occiput  and  the 
upper  portion  of  the  neck,  and  is  often  associated  with  sensations  of 
drawing  and  tension.  At  other  times,  though  less  frequently,  it  is 
referred  to  the  brow  or  to  the  vertex.  Often  other  sensations  are 
present,  such  as  pressure,  constriction,  giddiness  or  ringing  in  the  ears. 
These  sensations  are  not  themselves  the  direct  ovitcome  of  fatigue,  but 
belong  to  the  group  of  the  secondary  or  adventitious  symptoms,  men- 
tioned above.    They  may  or  may  not  be  present. 

JSText  in  frequency  to  headache,  patients  complain  of  backache. 
This,  at  first,  may  consist  of  a  simple  feeling  of  fatigue  referred  to  the 
lumbar  region,  which  is  relieved  by  lying  down,  but  which,  later,  may 
become  so  exaggerated  as  to  make  backache  the  most  prominent  feature 
of  the  case.  This  backache  is,  as  a  rule,  widely  diffused  over  the  lumbar 
region;  it  sometimes  extends  over  the  sacrum  and  gluteal  regions,  and 
at  other  times,  and  more  frequently,  upward  over  the  dorsal  region, 
especially  between  the  shoulder  blades.  Often,  cutaneous  hyperes- 
thesia makes  its  appearance,  so  that  the  back,  especially  over  the 
vertebra?,  becomes  sensitive  to  pressure.  Frequently,  this  painful 
hypersesthesia  is  present  in  spots  that  can  be  covered  by  the  tip  of  the 
finger.  It  is  found  especially  over  the  seventh  cervical  spine,  over  the 
upper  thoracic  spine,  sometimes  over  the  lumbar  spine  and  sacrum, 
and  very  frequently  indeed  over  the  coccyx.  Without  going  into  de- 
tails, it  may  be  said  that  these  symptoms,  which  were  formerly  and  in- 
correctly grouped  under  the  head  of  spinal  irritation,  clearly  belong  to 
the  secondary,  or  adventitious,  symptoms  of  neurasthenia.  Not  infre- 
quently, an  (;spf:ci;illy  i);iinrul  sfjot  is  foiiiHl  sliglilly  below  and  within 


858  ^  TEXT-BOOK  OF  GYNECOLOGY 

the  left  shoulder  blade.  Less  frequently,  a  painful  area  is  found  in  a 
similar  situation  below  the  right  shoulder  blade. 

Fatigue  aches  may  also  be  referred  to  the  limbs,  namely,  to  the 
arms  and  shoulders,  the  hips,  the  thighs,  or  the  legs.  They  consist,  as 
a  rule,  of  a  dull  aching,  which  is  diffused  through  the  tissues,  generally 
diminished  or  relieved  by  rest  and  made  worse  by  exertion.  Limb 
ache  is  not  infrequently  associated  with  the  special  occupation  of  the 
patient.  Thus  Dercum  has  observed  arm  ache  in  a  neurasthenic  pocket- 
book-maker,  leg  ache  in  neurasthenic  letter  carriers  and  collectors, 
and  not  infrequently,  as  a  matter  of  course,  in  neurasthenic  sales- 
women. 

When  we  turn  our  attention  to  the  phenomena  presented  hy  the  special 
senses,  we  find  that  the  symptoms  are  also  expressive  of  chronic  fatigue; 
but  without  stopping  to  analyze  them  here,  as  this  would  be  too  great  a 
departure  from  the  legitimate  object  of  this  chapter,  it  may  be  merely 
stated  that  the  symptoms  are  those  of  ready  exhaustion.  As  regards  the 
eye,  they  are  referable  to  fatigue  of  the  accommodative  apparatus,  of 
the  retina,  or,  it  may  be,  of  the  cerebral  centres.  One  of  the  common 
statements  which  we  hear  from  neurasthenics  is  that  they  can  not 
read  for  more  than  a  few  minutes  at  a  time,  that  the  letters  become 
blurred,  and  that  the  effort  gives  rise  to  pain,  generally  headache  or 
other  cephalic  distress,  such  as  vertigo.  Similar  truths  obtain  with  re- 
gard to  the  other  special  senses. 

When  we  turn  to  the  motor  symptoms  of  neurasthenia,  we  find  that 
these,  also,  are  expressive  of  fatigue.  They  consist  more  especially  of 
muscular  weakness,  which  develops  rapidly  under  exertion,  of  tremor, 
and  of  various  modifications  of  the  tendon  reactions.  The  -object  of 
this  chapter  forbids  their  discussion  in  detail,  as  well  as  a  consideration 
of  the  visceral  and  general  somatic  disturbances.  These  have  been  fully 
considered  elsewhere.  Suffice  it  to  say,  that  the  disturbances  of  circula- 
tion, of  digestion,  of  secretion,  and  of  the  sexual  functions  are,  all  of 
them,  manifestations  of  chronic  fatigue.  For  instance,  the  primary 
symptom  referable  to  the  digestive  tract  is  that  of  digestion  delayed 
and  enfeebled,  an  atonic  indigestion,  both  gastric  and  intestinal.  The 
disturbances  of  circulation  are  manifested  by  feebleness  of  the  pulse, 
coldness  of  the  extremities,  disturbances  in  the  rhythm. of  the  heart's 
action,  and  even  by  heart  murmurs.  The  disturbances  of  secretion 
are  evidenced  by  change  in  the  character  and  quantity  of  the  perspira- 
tion, of  the  urine,  and  of  the  saliva;  these  again  are  also  purely  and 
solely  related  to  fatigue.  Allien  we  turn  our  attention  to  the  psychic 
disturbances,  we  find  that  they,  too,  are  expressive  of  fatigue.  A 
marked  and  characteristic  sjmiptom,  namely,  the  diminution  of  the 
capacity  for  sustained  intellectual  effort,  is  invariably  present.  As  the 
patient  is  incapable  of  long-continued  physical  labour,  so  is  she  in- 
capable of  long-continued  mental  labour.  The  attempt  to  perform 
mental  labour,  sooner  or  later  brings  on  symptoms  of  exhaustion,  and  if 
the  task  is  persisted  in,  marked  fatigue  sensations  make  their  appear- 


PELYIC  DISEASES  AND   NERVOUS  AFFECTIONS  859 

ance,  especially  headache.  Associated  with  the  impairment  of  the 
power  of  sustained  effort,  there  is  a  lack  of  power  of  concentrating  the 
attention,  and  this  the  patient  frequently  mistakes  for  loss  of  memory. 
In  addition  to  these  symptoms,  there  is  a  lack  of  spontaneity  of  thought 
and  a  diminution  in  the  strength  of  the  will,  a  condition  of  general 
indecision  and  of  mental  and  emotional  irritability.  Frequently,  fear 
also  is  present,  and  may  assume  a  general  or  a  special  form;  in  the  latter 
case,  it  gives  rise  to  the  various  specialized  fears,  such  as  claustrophobia, 
agoraphobia,  etc. 

If  we  pause  to  analyze  the  primary  symptoms  of  neurasthenia,  we 
find  that  they  are  always  expressive  of  chronic  fatigue,  but  there  is 
present,  as  the  essential  condition,  not  only  a  marked  and  persistent 
diminution  of  nervous  energy,  but  also  an  increased  reaction,  mental 
and  physical,  to  external  impressions.  In  other  woTds,  to  nervous  weak- 
ness there  is  of  necessity  joined  nervous  irritability.  Diminished  re- 
sistance to  fatigue  implies  diminished  resistance  to  impressions  from 
without;  weakness  and  irritability  are  thus  necessarily  associated.  This 
is  seen,  for  instance,  in  the  motor  symptoms,  where  muscular  weakness 
is  associated  with  increased  reflex  excitability,  and  in  the  sensory  symp- 
toms, where,  to  the  fatigue  sensations,  there  are  sooner  or  later  added 
the  symptoms  of  local  hypereesthesia;  this  is  the  explanation  of  the 
hypersesthesia  so  often  found  over  the  spinous  processes,  over  the 
coccyx,  and  over  various  other  areas.  Another  illustration  of  the  same 
general  truth  is  found  in  the  fatigue  of  the  eye;  here,  the  patient  is 
not  only  unable  to  use  the  eyes  persistently,  but  there  is  also  present, 
sooner  or  later,  painful  hypersesthesia,  i.  e.,  an  irritability  of  the  eye 
to  light,  so  that  neurasthenics  often  begin  to  wear  smoked  glasses  of 
their  own  accord.  It  is  this  increased  reaction  to  impressions  from 
without  that  is  of  striking  importance,  as  we  shall  presently  see,  when 
we  deal  with  organic  affections  occurring  in  neurasthenic  subjects. 

Briefly  restating  the  facts,  we  find  that  the  two  cardinal  conditions 
of  the  fatigue  neurosis,  neurasthenia,  are  (1)  persistent  nervou.s  weak- 
ness, and  (2)  increased  nervous  irritability,  that  is,  increased  reaction 
of  the  organism  to  impressions  from  without.  When  we  apply  this 
interpretation  of  neurasthenia  to  the  study  of  the  diseases  of  the  vari- 
ous special  organs,  we  find  at  once  that  a  ready  explanation  is  pre- 
sented for  many  of  the  strange  facts  we  meet  with.  How  remarkable  it 
is  that  an  eye  defect  often  remains  undiscovered  for  years;  but  a  man 
who  has  become  neurasthenic  now  finds  that  exertion  of  the  eyes  brings 
on  headache,  or  makes  headache  worse,  if  present,  because  his  resistance 
to  fatigue  has  been  diminished;  in  other  words,  an  exertion  so  slight 
as  to  he  utterly  inadequate  to  evoke  any  symptoms  whatever  in  a 
healthy  man,  may  in  a  neurasthenic  rapidly  bring  on  a  fatigue  head- 
ache, now  termed  an  eye  headache.  In  the  same  way,  a  local  defect  or 
disease  in  other  portions  of  the  body  may  remain  undiscovered  so  long 
as  the  general  ]ic;ill  li  icmains  good,  and  may  only  make  itself  felt  when 
neurasthenia  hccouics  established — i.  e.,  when  the  nervous  system  pre- 


860  A  TEXT-BOOK  OF  GYNECOLOGY 

sents  the  phenomenon  of  increased  or  abnormal  reaction  to  local  im- 
pressions. This  fact  has  especial  application  to  gynecology.  It  is  well 
known  that  a  woman  with  a  laceration  of  the  cervix  or  perineum,  a 
displacement,  or  possibly  a  prolapsus,  of  the  ovary,  may  make  no  com- 
plaint so  long  as  her  general  health  remains  good;  not  infrequently, 
she  fails  to  seek  medical  advice  for  the  pelvic  condition  until  neuras- 
thenia has  become  established. 

The  foregoing  considerations  of  neurasthenia  warrant  the  following 
almost  self-evident  condusions: 

First,  that  neurasthenia  may  exist  independently  of  any  local  dis- 
ease, pelvic  or  otherwise. 

Secondly,  that  neurasthenia  and  pelvic  disease  may  exist  independ- 
ently in  the  same  individual. 

Thirdly,  that  when  pelvic  disease  is  present  with  neurasthenia,  the 
pelvic  symptoms  may  be  more  readily  recognised  by  the  patient  and 
therefore  become  more  prominent,  because  in  neurasthenia  the  reaction 
of  the  nervous  system  to  abnormal  or  pathologic  impressions  is  greatly 
increased.  Without  pausing  to  apply  these  conclusions  to  the  question 
of  surgical  intervention  let  us  turn  our  attention  to  hysteria. 

Hysteria,  as  has  already  been  stated,  is  one  of  the  two  leading 
neuroses  occurring  in  women.  Dercum  knows  of  no  affection  concern- 
ing which  there  is  still  so  great  a  lack  of  knowledge  in  this  country 
and  in  England,  notwithstanding  the  fact  that  the  French,  and  later 
the  Germans,  have  unmistakably  defined  and  described  the  symptom- 
atology of  this  disease.  We  frequently  hear  it  stated,  and  almost  as 
frequently  see  it  printed,  that  hysteria  is  a  disease  without  a  syndrome; 
that  it  is  a  disease  which  presents  an  "  infinitude  of  shifting  polymor- 
phic nervous  disturbances.^'  This  last  phrase  is  borrowed  from  a  text- 
book on  the  practice  of  medicine,  published  in  this  country  no  earlier 
than  1897;  and  nothing  could  be  more  untrue.  In  reality,  hysteria 
presents  a  syndrome  that  is  as  fixed  and  as  definite  as  that  of  any  other 
disease  with  which  we  are  acquainted. 

The  symptoms  of  hysteria,  particularly  its  cardinal  symptom,  like 
those  of  neurasthenia,  are  always  present  and  always  characteristic; 
while  it  is  equally  true  that  other  symptoms,  secondary  in  importance, 
are  from  time  to  time  added,  though  the  number  of  the  secondary  symp- 
toms is  far  less  than  those  met  with  in  neurasthenia.  Dercum  terms  hys- 
teria a  psychoneurosis  because  the  physical  symptoms  present  in  it  are 
dominated  by  mental  phenomena,  themselves  the  result  of  a  genuine  and 
profound  affection  of  the  cerebral  centres.  Prominent,  for  instance,  are 
emotional  disturbances  and  modifications  of  the  will,  but  to  these  are 
added  phj^sical  signs  so  striking  that  they  can  never  be  misunderstood. 
The  symptoms  of  hysteria,  like  those  of  neurasthenia,  consist  of  sensory, 
motor,  general  somatic  and  psychic  phenomena.  Let  us  begin  with  the 
sensory  symptoms.  In  neurasthenia,  the  sensory  symptoms  consist  for 
the  most  part  of  fatigue  sensations  combined  with  symptoms  of  sen- 
sory irritability.    In  hysteria,  on  the  other  hand,  fatigue  sensations  are 


PELVIC  DISEASES  AND   NERVOUS  AFFECTIONS  861 

absent,  but  instead  there  may  be  present  true  anaesthesia,  complete 
or  partial;  in  other  words,  we  are  at  once  impressed  with  the  fact  o± 
true  sensory  loss,  which  never  occurs  in  neurasthenia.  Further,  this 
sensory  loss  or  anesthesia  is  so  characteristic  as  to  enable  us  frequently 
to  make  a  diagnosis  of  hysteria  from  it  alone.  Allusion  need  only  be 
made  to  the  symptom  of  hemiansesthesia,  in  which  anesthesia  is  confined 
to  one  half  of  the  trunk  and  head,  and  to  the  limbs  of  one  side.  Strange 
to  say,  this  sensory  loss  involves  most  frequently  the  left  side.  Again, 
the  loss  of  sensation  may  be  less  widely  distributed,  in  which  case  it  is 
frequently  characterized  by  peculiarities  of  location;  for  instance,  it  may 
be  confined  to  a  segment  of  a  limb,  that  is,  it  may  extend  from  the 
elbow  to  the  wrist,  or  from  the  knee  to  the  ankle,  and  is  then  termed 
segmental  anaesthesia;  again,  it  may  cover  the  fingers,  hand,  wrist,  and 
the  arm  up  to  a  certain  level,  like  a  glove,  and  is  then  spoken  of  as 
glovelike  angesthesia;  or  it  may  cover  the  foot,  ankle,  and  the  leg 
up  to  a  certain  level,  and  then  is  spoken  of  as  stockinglike  angesthesia. 
At  other  times,  it  assumes  curious  geometrical  or  irregular  shapes.  A 
fact  which  strikes  the  observer  at  once  is  the  absence  of  correspondence 
between  the  various  areas  of  anesthesia  and  any  nerve  supply  or  any 
sensory  representation  in  the  spinal  cord.  This  fact  naturally  refers 
us,  while  seeking  for  the  seat  of  the  disturbance,  to  the  cerebrum.  As 
regards  hysterical  hemianesthesia,  this  cerebral  involvement  is  fur- 
ther rendered  probable  by  what  we  know  of  the  pathology  of  organic 
hemianesthesia,  and  it  becomes  still  more  probable  when  we  reflect 
that  the  facts  at  our  disposal  lead  us  to  infer  that  the  representation 
of  the  limbs  in  the  cortex  is  by  segments.  To  sum  up,  therefore;  in 
hysteria  it  is  the  distribution  of  the  sensory  loss  which  is  characteristic, 
and  which  at  once  stamps  it  as  hysterical.  An  important  fact,  however, 
should  in  this  connection  be  borne  in  mind,  and  that  is  that  the  sen- 
sory losses  in  hysteria  are  most  frequently  far  from  being  complete. 
Indeed,  the  most  frequent  condition  that  we  find  is  that  of  diminution 
of  respojise  to  tactile,  to  painful,  and  to  thermal  impressions,  there 
being  present  under  these  conditions  merely  a  general  lessening  of 
sensation,  a  hypo-esthesia,  or  hypesthesia — as  it  is  termed  technically. 
Partial  sensory  losses,  therefore,  having  the  peculiar  distribution  that 
has  been  stated,  are  as  unmistakable  in  their  significance  as  total  sen- 
sory losses,  which  are  less  frequently  met  with. 

Far  more  important,  however,  than  anesthesia  or  hypesthesia,  is 
the  hypercestJiesia  which  is  found  in  hysteria.  This,  also,  may  have 
a  most  varied  distribution,  but  as  a  matter  of  clinical  fact  it  seeks  by 
preference  certain  localities.  Thus,  most  frequently,  there  are  found 
areas  of  hyperesthesia  under  the  breasts,  so-called  "  inframammary 
tenderness,''  and  areas  of  hyperesthesia  above  the  groins,  grossly  mis- 
named "  ovarian  tenderness."  These  areas  of  hyperesthesia  are  some- 
times found  on  both  sides  of  the  body;  more  frequently,  however,  they 
are  limited  to  one  side  of  the  body,  and,  curiously  enough,  like  hemi- 
anesthesia, they  are  found  most  frequently  upon  the  left  side.     Areas 


862  A  TEXT-BOOK  OF  aYNECOLOGy 

of  hypersesthesia  are  also  frequently  found  upon  the  scalp,  and  here 
the  patch  is  often  so  small  that  it  can  be  covered  with  a  finger-tip. 

Not  infrequently,  these  areas  of  hyperesthesia  become  areas  of 
excessive  pain,  hyjDeralgesia.  The  areas  are  not  only  tender,  but  they 
become  painful — not  only  painful  to  touch,  but  spontaneously  painful. 
A  familiar  instance  is  found  in  the  hypergesthetic  area  upon  the  scalp, 
which,  when  spontaneously  painful,  gives  rise  to  severe  headache,  that 
form  of  headache  known  as  clavus  hystericus.  What  is  true  of  the 
hyperffisthetic  area  of  the  scalp,  is  also  true  of  the  hyperaBsthetic  area 
below  the  breast;  sometimes  it  centres  in  the  nipple  and  then  gives 
rise  to  mastodynia. 

That  both  clavus  and  mastodynia  are  affections  attended  with  much 
suffering,  no  one  will  deny.  AYhen  the  area  of  hyperesthesia  in  the 
inguinal  region  becomes  painful,  the  suffering  may  be  equally  great. 
Owing  to  the  anatomical  relation  which  the  inguinal  region  bears  to 
the  ovary,  inguinal  pain  has  been  greatly  misunderstood.  As  already 
stated,  it  has  been  misnamed  ovarian  tenderness,  and  has  been  directly 
attributed  to  the  ovary;  and  yet  there  can  be  no  doubt  with  regard  to 
the  nature  of  this  pain,  for  we  must  remember  that  it  is  quite  frequently 
found  in  men,  as  well  as  in  women  in  whom  the  ovaries  have  been 
removed — removed  sometimes  in  a  vain  attempt  to  relieve  this  pain. 
The  pain  is  not  ovarian;  it  should  never  have  been  called  ovarian. 
Inguinal  tenderness,  groin  pain,  or,  as  Dercum  prefers,  inguinodynia, 
are  terms  much  simpler  and  in  strict  accordance  with  facts.  The  pain 
is,  as  a  rule,  confined  to  a  limited  area,  and  is  found  most  frequently 
upon  the  left  side;  and  it  is  very  often  associated  with  a  similar, 
though  somewhat  larger,  area  of  tenderness  beneath,  or  over,  the  left 
mammary  gland,  and,  it  need  hardly  be  added,  with  other  definite,  well- 
marked  hysterical  stigmata.  As  a  rule,  it  is  revealed,  by  careful  exami- 
nation, to  be  superficial  and  not  deep.  It  is  situated  in  the  skin  and 
the  tissues  of  the  abdominal  wall,  and  not  within  the  pelvis.  Dercum 
has  frequently  demonstrated  this  to  be  a  fact  by  means  of  the  following 
procedure : 

The  painful  area  having  been  carefully  localized  on  the  abdominal 
surface,  the  tip  of  the  forefinger  of  the  right  hand  is  allowed  to  rest 
lightly  upon  it;  the  left  forefinger  is  then  introduced  into  the  vagina 
and  directed  upward  and  to  the  right,  until  its  tip  is  immediately  be- 
neath the  tip  of  the  forefinger  of  the  right  hand  which  is  upon  the 
abdominal  wall.  Just  as  soon  as  pressure  is  made  between  the  two 
fingers,  the  patient  flinches;  while  the  patient  does  not  flinch  when 
pressure  is  made  in  other  directions  or  when  other  portions  of  the 
abdominal  wall  are  included.  By  this  means  Dercum  has  succeeded 
not  infrequently  in  isolating  and  demonstrating  beyond  a  doubt  the 
site,  and  therefore  the  character,  of  this  pain.  In  some  cases,  just  as 
in  spinal  tenderness,  the  pain  radiates  and  becomes  somewhat  diffused; 
but  it  always  radiates  from  a  superficial  centre  in  the  abdominal  wall; 
and  just  as  there  are  cases  of  spinal  tenderness  in  which  the  tenderness 


PELVIC  DISEASES  AND  NERVOUS  AFFECTIONS  863 

is  at  one  time  superficial,  and  at  another  deep,  so  there  are  cases  of 
inguinal  tenderness  in  which  the  tenderness  seems  at  times  to  be  deep- 
seated;  but  even  here,  by  the  procedure  just  described,  the  maximum 
point  of  pain  can  always  be  isolated  and  shown  to  exist  in  the  abdom- 
inal tissues.  This  hysterical  inguinal  pain  has  frequently  forcibly  sug- 
gested to  Dercum  the  clavus  hystericus — the  boring  penetrating  pain 
that  hysterical  patients  feel  in  limited  areas  about  the  head;  and, 
indeed,  not  infrequently  this  inguinal  jaain  is  just  as  severe,  but  it  is 
no  more  intrapelvic  in  its  origin  than  is  the  clavus  of  the  head. 

It  is  not  necessary  to  speak  of  the  contracture  of  the  visual  fields 
in  hysteria,  nor  of  the  reversal  of  the  colour  fields,  as  they  do  not  in 
this  cha|)ter  directly  concern  us.  They  must,  however,  be  borne  in 
mind  as  affording  valuable  corroborative  evidence  of  the  existence 
of  hysteria.  The  motor  symptoms  of  hysteria  are  less  frequently  met 
with  than  the  sensory  disturbances  which  we  have  just  considered.  The 
motor  symj^toms  consist,  in  brief,  of  paralysis,  contracture,  tremor  and 
inco-ordination.  The  jaresence  of  motor  sym]3toms  generally  causes  the 
case  to  be  referred  to  the  neurologist  in  the  beginning,  rather  than  to 
the  gynecologist,  and  they,  therefore,  will  not  be  considered  in  this  con- 
nection. Similarly,  with  the  visceral  symptoms,  which  consist  of  dis- 
turbances of  digestion,  of  the  circulation,  of  the  heart,  of  respiration, 
of  fever,  of  cough,  of  loss  of  voice,  of  yawning,  of  phantom  tumours, 
etc.  They  also  are  less  likely  to  come  before  gynecologists  for  inter- 
pretation, and,  moreover,  are  so  characteristic  as  to  stamp  the  case  at 
once  as  hysterical. 

The  psychic  symptoms  of  hysteria,  however,  are  important  for  the 
gynecologist.  There  is  always  some  abnormity  of  the  mental  faculties 
in  hysteria,  more  particularly  a  hypersesthesia  and  irritability  of  the 
affectional  or  emotional  faculties.  The  patient  is,  as  a  rule,  exceedingly 
impressionable,  and  reacts  inordinately  to  impressions  involving  these 
faculties.  She  is  abnormally  sensitive  to  suggestions,  especially  with 
regard  to  her  physical  condition,  and  willingly  accepts  explanations 
attributing  her  symptoms  to  local  disease.  JSTot  infrequently,  hysterical 
symptoms  are  brought  to  the  surface,  or,  if  present,  are  made  promi- 
nent, by  the  ill-considered  statements  or  injudicious  interest  manifested 
by  the  patient's  friends.  It  can  be  readilv  seen  how  doubly  injurious 
under  such  circumstances  incautious  statements  by  a  physician,  or  a 
pelvic  examination,  even  when  the  latter  yields  a  negative  result,  may 
be.  One  can  hardly  judge  of  the  enormous  mental  impression  a  first 
examination  must  make  upon  a  young  girl,  especially  if  that  girl  is 
already  hysterical,  already  neuropathic  by  heredity  and  predisposition. 
Not  only  is  the  great  evil  of  the  moral  shock  to  be  taken  into  account, 
but  also  the  fact  that  tbere  is  lodged  in  the  patient's  mind  a  more  or 
less  vague  but  fixed  belief  tliat  she  has  some  mysterious  local  disease 
to  which  she  only  too  willingly  agrees  to  attribute  her  nervous  mani- 
festations. In  consequence,  she  sooner  or  later  insists  upon  a  repeti- 
tion of  the  exaininfil  ion  or  a  continuance  of  the  local  treatment  once 


864  A  TEXT-BOOK  OF  GYNECOLOGY 

begun,  and  the  morbid  idea  thus  implanted  may  become  hopelessly 
rooted,  never,  i^erhaps,  to  be  displaced.  The  enormous  role  which  the 
mental  condition  in  hysteria  plays,  must  constantly  be  borne  in  mind. 
Hysteria  appears  to  be  a  functional  disturbance  of  the  entire  nervous 
system,  but  with  a  special  involvement  of  the  cerebral  cortex. 

The  conclusions  that  the  above  considerations  justify,  are  the  fol- 
lowing: 

First,  that  hysteria  may  exist  independently  of  any  local  disease, 
pelvic  or  otherwise. 

Secondly,  that  there  is  no  essential  relation  between  pelvic  dis- 
ease and  hysteria,  even  when  the  two  affections  coexist  in  the  same 
case. 

Thirdly,  that  while  in  hysteria  there  is  an  increased  reaction  to 
external  impressions,  this  reaction  is  purely  psychic.  The  patient  is 
exceedingly  impressionable,  and  reacts  inordinately  to  impressions  in- 
volving the  affectional  or  emotional  faculties.  This  reaction  to  external 
impressions  differs  altogether  from  that  seen  in  neurasthenia,  for,  in 
the  latter,  the  reaction  involves  the  nervous  system  as  a  whole.  In 
hysteria,  the  jjatient  readily  accepts  the  suggestion — often  a  spontane- 
ous self-suggestion — of  pelvic  disease,  especially  as  groin  pain  is  so 
common  a  symptom  of  hysteria. 

Fourthly,  that  the  pain  areas  of  hysteria  bear  no  relation  to  dis- 
ease of  the  deeper  structures. 

Operations  for  the  Neuroses. — -Evidently  the  surgeon  can  not  hope 
by  operation  to  remove  the  symptoms  characteristic  of  the  neuroses, 
but  only  those  symptoms  properly  belonging  to  the  pelvic  disease  itself; 
and  his  operation  should  never  be  undertaken  for  any  other  purpose. 
To  state  the  truth  in  other  words,  the  surgeon  should  operate  for  the 
pelvic  condition  itself.  For  instance,  if  he  operates  on  a  tear  of  the 
perineum,  he  should  do  so  because  the  tear  has  resulted  in  mechanical 
difficulties — because  it  has  given  rise  to  a  displacement  of  the  uterus 
or  perhaps  to  a  rectocele,  not  because  the  tear  occurs  in  a  neurasthenic 
or  hysterical  woman.  If  he  removes  an  ovary,  it  should  be  because  the 
ovary  is  unmistakably  diseased.  If  he  removes  an  appendix,  he  should 
do  so  because  the  characteristic  symptoms  of  appendicitis  are  present, 
and  not  because  the  patient  suffers  from  neurasthenia  or  hysteria.  If 
he  sews  fast  a  movable  kidney,  it  should  be  because  the  mobility  of 
the  organ  is  such  as  to  threaten  mechanical  obstruction  of  the  ureter 
with  its  consequent  hydrops  of  the  kidney,  or  because  the  patient  suffers 
from  irregularly  recurring  attacks  of  gastro-intestinal  cramp  directly 
dependent  upon  the  abnormal  mobility  of  the  organ,  and  not  because 
she  is  neurasthenic  or  hysterical.  Operations  should  be  performed,  not 
for  the  relief  of  an  incidental  nervous  symptom,  but  because  of  the 
local  condition  itself;  just  as  we  set  a  broken  leg  in  an  insane  man, 
not  because  he  is  insane,  but  because  the  leg  is  broken. 

The  surgeon  should  approach  cases  of  neurasthenia  and  cases  of 
hysteria  somewhat  differently.     Contrary  to  what  might,  perhaps,  be 


PELVIC   DISEASES  AND   NERVOUS  AFFECTIONS  865 

inferred,  Dercum  believes  that,  in  neurasthenia,  operations  for  the 
cure  of  actual  pelvic  lesions  are  indicated,  and  should,  other  things 
being  equal,  be  performed.  We  remember  that  in  neurasthenia  there 
is  added  to  nervous  weakness,  nervous  irritability;  that  there  is  an  in- 
creased reaction  to  local  disease,  and  it  is  just  as  clearly  indicated  to 
correct  local  pelvic  disease  in  neurasthenic  patients  as  it  is  to  give 
such  patients  glasses  to  relieve  their  ocular  symjjtoms.  It  is  important, 
however,  in  considering  operations  upon  neurasthenics,  to  bear  in 
mind  that  these  patients  are  excessively  sensitive  to  nervous  shock.  All 
gynecologists  are  familiar  with  the  persistent  nervous  symptoms — the 
persistent  surgical  neurasthenia — that  ensues  in  some  patients  after 
jDclvic  operations.  If  such  operations  are  undertaken  u23on  persons 
already  neurasthenic,  great  harm  may  be  done.  Therefore,  if,  in  a 
<3ase  requiring  pelvic  operation,  neurasthenia  is  present  in  any  degree 
(provided,  of  course,  that  the  operation  is  not  urgently  indicated  for 
•surgical  reasons),  Dercum  believes  that  the  patient  does  better  if  the 
•operation  is  preceded  by  a  j^eriod  of  rest.  If  the  patient,  instead  of 
being  neurasthenic,  is  hysterical,  a  period  of  i^reliminary  rest  is  even 
more  strongly  indicated.  This  he  believes  to  be  specially  true  when 
the  hysteria  is  very  profound.  In  the  latter  case,  operation  should  be 
deferred,  unless,  of  course,  the  surgical  indications  are  urgent. 

Nervous  Symptom^  of  Pelvic  Disorders. — A  view  is  entertained  by 
many  physicians  that  certain  nervous  disorders  are  the  direct  result  of 
pelvic  lesions.  Unfortunately,  the  increase  of  our  knowledge  regarding 
functional  nervous  diseases  does  not  bear  out  these  assertions.  The 
nervous  symptoms  caused  by  pelvic  disease  are,  as  a  matter  of  fact, 
exceedingly  limited.  It  is  true  that  there  is  present  pelvic  pain,  pain 
referred  to  the  back  and  to  the  hips  and  thighs,  together  with  more  or 
less  marked  indications  of  general  ill-health,  but  certainly  these  symp- 
toms can  not  be  dignified  by  the  term  of  a  nervous  disorder.  They  are 
a  part  of  the  pelvic  disease  itself,  and  are  directly  symptomatic  of  it. 
They  do  not  constitute  neurasthenia  or  hysteria. 

]\Iany  years  ago  a  doctrine,  known  as  the  doctrine  of  reflex  nervous 
disorders,  had  an  exceedingly  strong  hold  u^^on  the  profession.  An 
increasing  knowledge  of  the  various  functional  nervous  diseases  has 
demonstrated  this  doctrine  to  be  utterly  fallacious.  Long  since,  the 
practice  of  circumcision  for  ei^ilepsy  has  been  abandoned,  as  has  also 
the  removal  of  ovaries  for  the  cure  of  the  same  disease  and  of  hysterical 
convulsions.  Both  procedures  had  equally  little  foundation  and  both 
were  equally  unscientific  and  barbarous. 

The  reader  can  readily  understand  why  it  is  unnecessary  to  discuss 
the  relation  between  the  pelvic  disease  and  epilepsy,  chorea,  and  other 
nervous  diseases.  The  truth  can  all  be  summed  up  in  a  word,  there  is 
710  relation.  The  same  truth  obtains  with  regard  to  the  insanities.  For 
instance,  the  various  abnormities  of  menstruation  that  are  observed 
in  the  course  of  an  insanity,  are  the  indirect  sequela?  of  the  general  ill- 
lie;!  lib  from  wliifli  IIk;  paiifnt  suffers,  and  not  due  to  any  apocryphal 


866  A  TEXT-BOOK  OF  GYNECOLOGY 

relation  between  the  condition  of  the  pelvic  organs  and  the  insanity.. 
Insanity,  like  epilepsy,  depends  upon  morbid  changes  within  the  ner- 
vous system  itself;  these  changes  in  turn  being  dependent,  in  all  proba- 
bility, upon  profound,  and  as  yet  undetermined,  changes  in  the  general 
nutrition  of  the  organism.  The  statement  is  sometimes  made  that 
insane  patients  who  have  been  subjected  to  operation  sometimes  get 
well,  but  we  should  remember  that  a  lucid  interval  or  even  an  apparent 
cure  sometimes  follows  a  mere  physical  shock,  such  as  a  fall  or  other 
trauma.  Indeed,  a  recovery  is  not  an  infrequent  result  of  some  inter- 
current infectious  malady,  such  as  erysipelas  or  typhoid  fever. 

A  full  and  dispassionate  consideration  of  the  entire  subject  leaves 
to  the  surgeon  no  other  option  than  to  operate  for  surgical  indications- 
only;  and,  in  certain  cases,  where  the  nervous  disorder  is  grave,  as  in 
profound  hj^steria,  profound  neurasthenia,  and  in  insanities  attended 
with  great  exhaustion,  operation  should  be  undertaken  only  when  the- 
surgical  indications  are  urgent.     (See  Indications  for  Oophorectomy.), 


INDEX 


Abbe,  692. 

Abdomen,   auscnltation  of,  40. 

bandage  for.  111;  illus.,  p.  112. 

massage,  24. 

nonpeudulous,  466. 

pendulous,  466;  illus.,  p.  467. 

percussion  of,  40. 

palpation  of,  40. 

regions  of,  41;  illus.,  41. 
Abdominal   section,   99. 

drainage  in,  114. 

instruments  foi',  103. 

location  of  incision,  103. 

making  the  incision,  107. 

preliminary  treatment  for,  100. 

preparation  of  field,  66. 

terminology,  99. 
Abel,  362,  389,  .556. 
Abortion,  as  a  cause  of  menorrhagia,  716. 

as  a  cause  of  metrorrhagia,  719. 

criminal,  10. 

tubal,   655. 
Abscess,  ischiorectal,  826. 

kidney,  768. 

metastatic,  57,  58. 

pelvic,    689. 

vulvo-vaginal  gland,  245. 
Absence  of,  Fallopian  tubes,  473. 

hymen,  133. 

kidney,  849. 

ovary,   560. 

rectum,  806. 

uterus,  276. 

vagina,   126. 
Adamkiewicz,  442,  443. 
Adams,  294. 
Adenoma  malignum  evertens,  430. 

invertens,  4.30;  illus.,  p.  431. 
Adenoma,  of  kidney,  782. 
histology,  782. 

ovary,   contents,  620. 
histology,   620. 

rectum,  841. 
symptoms,  842. 
treatment,  842. 

uterus,  429. 
cautery   in,    431. 
curettage  in,  431. 
hemorrhage  from,  431. 
recurrence  of,  432. 
treatment,  431. 


Adenomyoma  of  uterus,  397,  399. 
Adenosarcoma  of  kidney,  783. 

histogenesis,  784. 
Adhesion,  as  a  complication  of  ovarian  tu- 
mours, 631. 

inguinal,  297. 

labial,  120,  212. 

of  movable  kidney,   717. 

preputial,  120,  211. 
treatment,  212. 

rectal,  832;  illus.,  822. 

separation  of,  547;  illus.,  p.  548. 

treatment  of,  294. 

treatment  of,  in  ovariotomy,  642. 

vulvar,  211. 
Accidents,  in  anaesthesia,  95. 

hj'sterectomy,  415. 
Acconci,  576. 
Aetius,  1. 
Afanassiew,  166. 
Ahlfeld,  436. 
Air  embolism,  74. 

in  use  of  chloroform,  94. 
Albarran,  747,  760,  763,  764,  767,  772,  791. 
Albicans  oidium,  167. 
Albuminuria,  681. 
Alcohol,  as  an  anaesthetic,  97. 
Alexander,  294,  295,  297,  303,  305,  309,  324, 

361,  564. 
Alexander's  operation  on  round  ligament, 

294. 
Allingham,  855. 
Allis  inhaler,  92;  illus.,  p.  92. 
Aloe,  835. 
Alquie,  294. 
Altormyan,  394. 
Alyard,  448. 
Amann,  434,  440. 
Ameiss,  278,  279. 
Amenorrhcea,  acquired,  721. 

frequency  of,  720. 

treatment,  721. 
Amputation   of  the   cervix,   340;  illus..    p. 

342. 
Ansemia,  as  a  cause  of  amenorrhcea,  722. 

as  a  cause  of  menorrhagia,  714. 

causes,  722. 

treatment,   722. 
Anaeslhesia,   87. 

accidents  in,  95. 

alcohol   in,   97. 

867 


868 


A  TEXT-BOOK  OF  GYNECOLOGY 


Anaesthesia,  cause  of  bronchitis,  91. 
central,   97. 

cyanosis  in,  90. 

for  children,  91. 

hypnosis  for,  98. 

in  examination,  40. 

kidneys  in,  102. 

local,    98. 

manipulation  of  head,  96. 

sexual,   9. 

struggling  in,  90. 

vomiting  in,  91. 
Anaesthetic  agents,   87. 

selection  of,  88. 
Anatomy,  of  corpus  luteum,  13. 

Fallopian  tubes,   489. 

hair  follicle,  199. 

movable  kidney,   755. 

parovarium,  670. 

pelvic  floor,   250. 

rectum,  806. 

urachus,  803. 

vulvo-vaginal  glands,  243. 
Anderson,  41. 
Andrews,  Edmund,  441. 
Angeiodystrophia   ovarii,    17. 
Angeioma  of  kidney,  781. 

rectum,  843,  844. 
Angeiosarcoma,  624. 
Angeiotribe,  81. 

for  hemostasis.  81. 

in  panhysterectomy,  illus.,  p.  419. 
Animal  extracts,  21. 
Animals,   menstruation  of,   699. 
Anomalies,  see  Malformations. 
Anoscope,   812. 

use  of,  814. 
Ante-deviations  of  the  uterus.   310. 

cuneohysterectomy  for,   315. 

curettage  for,  312. 

diagnosis  of,  310. 

dilatation  for,  312. 

pathology  of,  311. 

surgical  treatment  of,  312. 

symptoms  of,  310. 

treatment  of,  311. 
Antisepsis,  56,  60. 

post-operative,   68. 

precautions  for,  295. 
Anuria,  780. 
Anus,  Assure  of,   820,  832. 

imperforate,  120. 

malformations  of,  806. 

ulcer  of,  832. 

vulvar,  121;  illus..  p.  122. 
Aphthae  of  external  genitalia,   179. 

treatment,  179. 
Apostoli,  24,  680. 
Appendicitis,  diagnosis  of,  504. 
Appetite,   sexual,   588. 
Approximation  of  abdominal  incision,  104, 

105. 
Aretseus,  328. 
Arloing,  180. 
Armanientarium,  27. 


Armamentarium,  gynecological,  27. 

ofHce  examination,  31. 
Aron,  388. 
Asche,  235. 
Aschoff,  231,  769. 
Ascites,  630. 

as    a    complication    of    ovarian    tumour, 
635. 
Asepsis,  56. 

Ashton,  W.,  348,  349,  735. 
Askanazy,  174. 
Aspiration,  546. 

as  a  means  of  examination,   47. 

instrument  for,  546;  illus.,  p.  546. 
Assault,  indecent,  160. 
Astringents,  22. 
Astruc,  1. 
Atlees,  638. 
Atmocausis,  367. 

Atresia  ani  vestibularis,  221;  illus.,  p.  122. 
Atresia,  of  cervix,  279. 

Fallopian  tubes,  495. 

hymen,  132. 

ureters,  150. 

vagina,  126;  illus.,  p.  127. 

vulva,  119;  illus.,  p.  119. 
Atrophy  of,  ovaries,  592. 
causes,  592. 
symptoms  and  treatment,  593. 

uterus,  18. 

vulva,  207;  illus.,  p.  208. 
diagnosis,   210. 
etiology,  208. 
treatment,  210. 
Auscultation  of  abdomen,  40. 
Auto-infection,   165. 
Avicenna,  328. 
Aveling,  329. 
Ayner,  764. 

Bacilli,  53;  illus.,  p.  54. 
Bacillus   aerogenes   capsulatus,    54:  illus., 
p.  58. 

infection  by,  180. 
Bacillus  coli  communis,  illus.,  p.  54. 
Bacillus  coli  infection  of  Fallopian  tubes, 
487,  528. 

causes,  528. 

pathology,  529. 

symptoms,  .528. 
Bacillus  coli,  infection  of  ovary,  575. 
Bacillus  diphtheria,  167. 
Bacillus  phlegniouis  emphyseniatosus,  ISO. 
Bacillus  tuberculosis,  55;  illus.,  p.  54. 

infection  by,  see  tuberculosis  of. 
Bacini,  677. 
Bacon,  18.  212,  427. 
Backer,  358. 
Bacteria  of,  cervix,  353. 

chancroid,  183. 

cystitis,  791. 

Fallopian  tubes  in  disease,  484. 
in  health,  484. 
methods  of  access,  486. 

external  genitalia,  163. 


INDEX 


869 


Bacteria  of  lochia,  166. 

ovaries,  570. 

puerperal  fever,  376. 

pyosalpinx,  485. 

renal  infection,  769. 

salpingitis,  484. 

sepsis,  18. 

uterus,  352. 

vagina,  163. 
Baer,  720,  740. 
Bagot,  683. 

Baldy,  136,  257,  678,  680. 
Ball,  John,  312,  313,  8.33. 
Ballantyne,    120,    121,    122,    123,    124,    127, 
131,   133,   134,   279,   318,   473,   474,   475, 
562. 
Ballottement,  634. 
Ballowitz,  749,  750. 
Balneotherapy,  22. 
Band,  vestibular,  131:  illus.,  p.  132. 
Bandage,  abdominal.  111;  illus.,  p.  112. 
Bandelocque,  463. 
Bandl,  331,  683. 

ring  of,  332. 
Bandouin,  294. 
Bangs,  774. 
Bantock,  588,  6 
Barbier,  131. 

Barnes,  Robert,  329,  461,  649,  700,  711. 
Barth,  478. 

Bartholin,  glands  of,  243. 
Bartlet,  H.  L.,  459. 
Baruch,  367. 
Basedow,  712. 
Bath,  sitz,  204. 
Battey,  2,  584,  723. 
Battey's  operation,  584. 
Battle,  778. 
Beaucoudray,  617. 
Becker,  753. 
Bell,  638. 
Benbrook,  346. 
Bennet,  2. 
Berggriin,  694. 
Bergh,  200. 
Bergmann,  von,  24. 
Bernard,  192,  763. 
Bernitz,  649. 
Bernliardes,  279. 
Bettman,  209. 
Bicornate  uterus,  281:  illus.,  p.  279. 

menstruation  from,  280. 
symptoms,  278. 
Bigcard,  458. 
Bilharz,  ISO. 

Bilharzia,  of  vagina,  180. 
Billroth,  24,  038.  626. 
Bimanual  examination,  37:  illus..  p.  37. 
Birch,  781,  78.3. 
I'.itncr,  12.3. 
I'.lafkr-r,  .562. 

Bladder,  calculus  in,  140,  141. 
congest  iou  of,  780. 
inrcfllori  of.  701. 

infl:ijiini;il  i'.ii  uf.  T;iO. 


Bladder,  neuralgia  of,  795. 

tumours  of,  798. 
Blondel,  277. 
Blood  cyst,  of  corpus  luteum,  600. 

structure,  601;  illus.,  p.  601. 
Blood,  examination  of,  49. 

extravasation  of,  492. 

transfusion  of,  76. 
Bloom.  737. 
Blot,  473. 
Blumer,  514. 
Blundell,  471. 
Bockart,  53,  198. 
Bode,  294. 

Bodenhamer,  806,  807. 
Bodenstein,  867. 
Boeck,  Cajsar,  216. 
Boisleux,  503. 
Bossi,  370. 
Bovee,  477,  647,  648. 
Bouilly,  458. 
Bowditch,  5. 
Bozeman.  148. 
Bozeman's  dressing  forceps,  illus.,  p.  369. 

table,  143. 
Braetz,  434. 
Brain  wei.ght,  7. 
Brandt.  Thure,  25,  353,  3.59. 
Braun.  Carl.  180,  .324,  329,  681. 
Braxton-Hicks,  725. 
Brehmer.  692. 
Breisky,  207,  208,  429. 
Brenner,  747. 
Broese,  372,  373. 
Bromide  of  ethyl,  as  an  ansesthetic,  91. 

administration  of,  95. 
Bronchitis  as  a  result  of  ansesthesia,  91. 
Brosson,  204. 
Brown,  Baker,  638. 
Browne,  Sir  J.  Crichton,  7. 
Brues,  389. 
Bruhn,  229. 
Brunn,  692. 
Bubo,  515. 

chancroidal.  181. 

internal.  392. 
Buchner.  098. 
Buckmaster.  122. 

Buds,  syncytial,  427;  illus.,  p.  428. 
Bulbo-cavernosus  muscle,  250. 
Bulius,  17.  599,  610,  695. 
Bulkley,  206. 
Bullard,  J.  W.,  257. 
Bumm,   16.   52,   53,   244,   246,   .353.   334,   376, 

377.  378,  379,  517,  617,  698.  791. 
Burns,  462. 
Burow,  19.3,  196. 
Byford,  257,  294.  301,  302,  546. 
Byrne,  .Tohn,  83,  456,  4.58.  4.59. 
Byrne's    electro-hysterectomy,    4.56:  illus.. 
p.  546. 

Csesarean  scriion,  460. 
after-troatmont,  470. 
closure  of  uterus,  469. 


870 


A  TEXT-BOOK  OF  GYNECOLOGY 


Csesarean  section,  dangers  of,  465. 
definition,  460. 
diet,  after  operation,  470. 
drainage  after,  469. 
hemorrhage  in,  467. 
history,  460. 
indicatioris,  463. 
instruments,  465. 
ligation  of  tubes,  469. 
location  of  incision,  466;  illus.,  466.  4G7. 
manipulation  of  foetus,  467. 
measurement  of  pelvis,  464. 
position  of  fcetus,  465. 
Porro"s  modification,  471. 
preparation  of  patient,  465. 
removal  of  placenta,  468. 
removal  of  sutures,  470. 
results,  462. 

rupture  of  membranes,  470. 
Sanger's  method  of  closure,  470. 
technique,  466. 
treatment  of  tubes,  468. 
Calcareous    tumours    of,    corpus    luteum. 
617. 
ovary,  615. 
etiology,  617. 
histology,  616. 
treatment,  618. 
Calculi,  renal,  776. 
etiology,  776. 

pathological  changes,  778. 
primary,  776. 
removal  of.  761. 
secondary,  777. 
stricture  from,  761 
symptoms,  778. 
treatment,  780. 
Calculi,  vesical,  140,  141.  7>.Mi. 

removal,  798. 
Calyces,  dilatation  of,  763. 
Cameron,  462,  463,  465,  471. 
Camescasse,  514. 
Canquoin,  366,  370. 
Capsularis,  in  ectopic  pregnancy,  6-58. 
Carcinoma,  bacillus  of,  441. 
Carcinoma  of,  broad  ligament,  386. 
cervix,  362,  438. 
ovary,  619. 
adenocarcinoma,    620;  illus.,    p.    620. 
medullary,    619. 
primary,    619. 
secondary,   022. 
portio  vaginalis,  438. 
rectum,  844. 
stricture  from,  838. 
symptoms  of,   845. 
treatment,  845. 
urethra,  801. 

iiterus,  447;  illus.,  p.  440. 
age  influence,  440. 
amputation  of  cervix  for,  447. 
cauterization  for,  447. 
complications,  443. 
course,  439. 
cnrettement  for,  447. 


Carcinoma  of  uterus,   diagnosis  of,  442. 
diagnosis,  by  inoculation,  443. 
discharge  in,  442. 
electro-hysterectomy  for,  456. 
etiology,  440. 

extended  operation  for,  453. 
hemorrhage  in,  442. 
histology  of,  439. 
hysterectomy  for,  447. 
involvement  of  lymphatics,  439. 
metastasis  from.  481. 
mortality  in,  437. 
mortality  from  operations,  458. 
origin,  438,  441. 
panhysterectomy  for,  417. 
pathology.  438. 
pregnancy  in,  443. 
prognosis,  444. 
radical  treatment,  447. 
recurrence  of,  458. 
results  of  hysterectomy,  458. 
removal  of  vagina  for,  455. 
serum  treatment,  446. 
symptoms,  442. 
tampon  for,  446. 
topical  medication,  444. 
vaginal  hysterectomy  for,  447. 
vagina,  233. 
primary,  233. 
secondary,  234. 
vulva,  227. 
classification,  227. 
prognosis,  228. 
vulvo-vaginal  gland,  228,  249. 
Carniso,  470. 

Carstens,  444.  445,  446,  453. 
Cartledge,  377,  383,  603. 
Caruncle,  urethral,  800. 

treatment,  801. 
Casper,  772,  747. 
Castex,  328. 
Castration.  407. 
Catgut,  suture,  67,  3.37. 
Catheter,   glass;  illus.,   p.   368. 

use  of,  148. 
Catheterization  of  ureters,  746. 
by  cystoscope,  747. 
Pawlik-Kelly  method,  746. 
Caustic,  in  treatment  of  syphilis,  190. 
Cauterization,  for  carcinoma,  445. 
condylomata,  210. 
hemorrhoids,  853. 
hemostasis,  80. 
syphilis  of  uterus,  393. 
tubercular  endometritis,  391. 
Cautery,  Paquelin's,  80. 

thermo-,  in  vaginal  hysterectomy,  449. 
Cazeaux,  463. 
Cazin,  427,  428. 
Celsus,  852. 

Central  ansesthesia,  97. 
Cervix,  amputation  of,   340;  illus.,  p.  342. 

for  carcinoma,  447. 
Cervix,  atresia  of,  279. 
bacteria  of,  352. 


INDEX 


871 


'Cervix,  carcinoma  of,  362,  438. 

chancre  of,  392. 

dilatation  of,  356,  364,  421,  726. 

eversion  of,  392. 

fixation  of,  304. 

function  of,  350. 

hypertropliy  of,  319,  335;   illus.,  320. 

immunity  of,  355. 

in  endometritis,  364. 

laceration  of,  334. 

menstruation  from,  435. 

secretion  of,  353.. 

tuberculosis  of,  385. 
■Cliadwick,  394. 

•Chain  tampon,  292;  illus.,   p.  292. 
Chamberlain,  61,  461. 
■Chancre,  cervical,  392. 

ecthymatous,  185. 

exulcerated,  186. 

hard,  184,  201. 

pudendal,  181. 

rectal,  828. 

uterine,  391. 
'Chancroid,  181. 

course  of,  182. 

diagnosis  of,  175,  183. 

pathology,  183. 

prevalence,  182. 

phagedenic,  181. 

rectal,  828. 

treatment,  184. 

vulvar,  228. 
"Chancrous  erosion,  185. 
Chantemesse,  379. 
Charcot,  98. 
Chase,  W.  D.,  721. 
Chassaignac,  808. 
Chenieux,  686. 
Cheyne,  750. 
Chiari,  180,  521. 
Chiarleoni,  120. 

•Childbirth,     as     a     cause     of    disease     in 
women,  10. 

as  a  cause  of  uterine  disphicement,  206. 
■Children,  anaesthesia  for,  91. 
■Chloroform,  administration  of,  94. 

inhaler,  94. 

relative  safety  of,  88. 
■Chlorosis,  as  a  cause  of  menorrhagia,714. 
Chorio-epitlielioma,  see  Syncytioma  malig- 

num. 
Chrobak,  580. 

Cilia,  of  endometrial  epithelium,  .351. 
Circumcision,  120,  220. 
Cirrhosis,  of  ovaries,  .593. 

causes,  593. 

syitir)tonis,  treatment,  594. 
C'i vilizaliriii,  as  a  cause  of  disease,  6. 
Clado,  791. 
Claisse,  682. 

Clark,  13,  115,  478,  479,  488,  490,  .5.34. 
Clavus  hysfcricux,  862. 
Clay,  4r?f;,  638. 

rianiii,  cl'clric.  In  panliysterectomy,  419. 
<Mitoridcctomy,  2.34;  Illus.,  p.  2.34,  2.35. 


Clitoris,  diseases  of,  see  Vulva. 

epithelioma  of,  228;  illus.,  229. 

excision  of,  234;  illus.,  p.  234,  23.5. 

glands  of,  118. 

hypertrophy  of,  126,  213. 

malformations  of,  124. 
Clivio,  52,  178,  376. 
Cloaca,  117. 

persistent,  121;  illus.,   p.  122. 
Closure  of  abdominal  incision,  109. 

of  perineal  incision,  260,  265. 

of  uterine  incision,  469. 

for  drainage,  113,  111. 
Clover's  crutch,  260. 
Cocaine,  as  an  auEesthetic,  97. 
Cocci,  pyogenic,  165. 
Coe,  257,  429,  431,   478,   480,   538,   540,   547, 

551,  592,  617,  670. 
Cceliotomy,  see  Abdominal  section. 
Cohn,  622. 
Cohnheim,  609,  617. 
Cohnstein,  711. 
Coitus,  119. 

as  a  cause  of  disease,  9. 

injuries  from,  136. 
Coitus  reservatus,  10. 
Cold,  in  anaesthesia,  89. 

in  treatment  of  sepsis,  56. 
Coley,  436. 

Colica  scortorum,  502. 
Colley,  100. 
Collodion,  111. 
Colombeni,  374,  375. 
Colostomy,  846. 

for  rectal  prolapse,  820. 
Colporrhaphy,  anterior,  241;  illus.,  p.  239. 

posterior,  242. 

technique,  323. 
Coma,  alcoholic,  97. 
Comby,  754. 

Commissure,  vulvar,  123. 
Compress,  for  pruritus  vulvae,  205. 
Conception,  prevention  of,  10,  469. 

relation  to  menstruation,  711. 
Condylomata,  187,  213;  illus..  p.  214. 

cauterization  of,  216. 

mieroscropic  examination  of,  214. 

rectal,  828;  illus.,  p.  829. 

treatment,  215. 
Conservatism,  in  gynecology,  4. 

in    operations    on    the    Fallopian    tubes, 
546. 

in  operations  of  the  ovary,  543. 
Constipation   as   a   cause  of  amenorrhoea, 
722. 

as  a  cause  of  genital  disorders,  9. 

as    a     cause    of    uterine    displacement, 
286. 

as  a  cause  of  rectal  disease,  507. 

from  obstruction;  illus.,  p.  508. 

treatment,  100,  321,  717. 
Cook,  733. 
Cooper,  844. 
Cordier,  .326,  604. 
Cornll,  386,  387,  388,  389. 


872 


A  TEXT-BOOK   OF   GYNECOLOGY 


Corning,  J.  Leonard,  97. 
Corpora  cavernosa  clitoridis,  118. 
Corpus  luteum,  anatomy  of,  13. 
calcareous  tumours  of,  617. 
cj'sts  of,  599. 
Corpus  luteum  verum,  660. 
Corpus  spongiosum,  118. 
Corset,  as  a  cause  of  genital  disorders,  8. 

as  a  cause  of  movable  kidney,  54. 

dangers  of,  729. 
Couglilin,  733. 
Courty,  281. 
Crab  louse,  206. 
Cragin,  750. 
Craig,  Thomas  C,  51. 
Craniotomy,  results  of,  462. 
Crampton,  327. 
Crile,  72,  75. 
Criminal  abortion,  10. 
Cripps,  844. 
Crosse,  327. 
Crown  suture,  Emmet's,  262:  illus..  p.  262. 

Reed's,  263;  illus.,  pp.  264,  265. 
Crutch,  Clover's,  260. 
Cullen,  389.  497. 
Cullen's  tenaculum,  450. 
Cullingworth,  281. 
Cuneohysterectomy,  anterior,  310. 

modifications,  317. 

posterior,  315;  illus.,  p.  .316. 

technique,  316. 
Curatullo,  589. 
Curettage,  368. 

after-treatment,  371. 

anaesthesia  for,  92. 

contraindications,  369. 

exploratory,  364. 

for  adenoma  uteri,  431. 

for  ante-deviations  of  uterus,  312. 

for  carcinoma  uteri,  444. 

for  puerperal  fever,  381  . 

for  tubercular  endometritis,  391. 

indications,  313,  369. 

instruments  for,  368. 

rectal.  846. 

technique,  313. 
Curette,  Gau's,  346;  illus.,  p.  346. 

Martin's,  568. 
Currier,  6,  369. 
Cushing,  Clinton,  541. 
Cyanosis,  in  anaesthesia,  90,  94. 
Cycle,  menstruable,  stage  of  degeneration 
709. 

stage  of  growth,  708. 

stage  of  recuperation,  709. 

stage  of  rest,  708. 
Cyst,  dermoid,  14,  224,  225,  611. 

emptying  of,  in  ovariotomy,  641. 

tubo-ovarian,  498. 
Cyst  of,  Bartholin's  gland,  228. 

broad  ligament,  674. 
causes,  674. 
complications,  674. 
contents,   673. 
development,   672. 


Cyst  of,  broad  ligament,   diagnosis,  674. 

enucleation,  676. 

frequency,  671. 

history,    671. 

origin,  671. 

pain  in,  674. 

rupture  of,   675. 

symptoms,    674. 

technique   of  operation,    676. 

treatment,   675. 
corpus  luteum,  594;  illus.,  p.  600. 

blood  cysts,  600. 

contents,  600. 

development,   599;  illus.,   p.   600. 

etiology,  600. 

histology,   600. 

structure.   601:  illus.,  p.   601. 
Gartner's  duct,  224. 
hymen,  224. 

Kobelt's  tubules;  illus.,  p.  475. 
ovary,  597. 

characteristics,   597. 

corpus  luteum  cysts,  599. 

dermoid,   611. 

follicular  cysts,   598;  illus.,   p.   598. 

malignant   degeneration,    611. 

papillary  cysts,  607. 

papillomata,   609. 

pseudomucinous,    603. 

puncture  of,  637. 

rupture,   631. 

serous,  607. 

teratoma,   614. 

tubo-ovarian,   601. 
rectum,  844. 
uterus,  394. 
urachus,  815. 

treatment,  815. 
vagina,  224;  illus.,  p.  225. 
vulva,  223. 
vulvo-vaginal  gland,  247. 

histology,  247. 

treatment,  249. 
Cystadenoma  of,  kidney,  782. 

ovarj',   18,   621;  illus.,    p.    662. 
Cystitis,  2.57. 
bacteria  of,  791. 
definition,  790. 
diagnosis,  793. 
etiology,  790. 
pathologic  changes,  792. 
pus  from,  79.3. 
symptoms,  793. 
treatment,  794. 
urine  in,  793. 
Cystocele,   2.38;  illus.,   p.   238. 

operation  for,  241;  illus.,  p.  239. 
Cystoma,  parovarian,  671. 
tubal,  480. 
origin,  480. 
Cystonephrosis,   &ee  Nephrocytosis. 
Cystoscope,  illus.,  p.  748. 

use  of,  749. 
Czerniewskl,  52,  376. 
Czerny,  333,  447. 


INDEX 


873 


Da  Costa,  727. 

Dai'tlgues,  751. 

Daui'ios,  385. 

Davenport,  634. 

Davidsohn,  176. 

Davidson,  76. 

Davies,  100. 

Deaver,  528. 

Depaul,  463. 

Debility  as  a  cause  of  menorrhagla,  714. 

Decldua  of  etopic  pregnancy,  656. 

Deciduoma  mallgnum,  see  Syncytioma  ma- 

llgnum. 
Deciduoma  sarcoma,   see  Syncytioma  ma- 
llgnum. 
Delagenlere,  114,  125,  281,  282,  305. 
Delbet,  682. 
Demme,  171. 
Deneaux,  137. 
Denuce,  797. 

Denudation  for  trachelorrhapliy,  339. 
Depas,  202. 

Dercum,  856,  858,  860,  862,  863,  864,  865. 
Dermoid  cysts,  14,  611. 

contents,  611. 

liistologj-,  611. 

malignant    degeneration,    614;  illus.,    p. 
614. 

origin,  613. 

of  ovary,  67. 

rectum,  844. 

vagina,  225. 

vulva,  224. 
Descensus  of  ovary,  563. 

of  uterus,  317. 
De  Slnerty,  172,  711. 
Desplans,  692. 
Deutsch,  335. 

Development  of  genital  organs,  117. 
Deviations  from  pathological  laws,  12. 
Dewille,  520. 

Diabetes  as  a  cause  of  pruritus  vulvae,  204. 
Diagnosis,  29. 

curettage  for,  364. 

digitation  for,  364. 

scope,  29. 
Diaphragm,  pelvic,  253,  284. 
DiarrhcEa  as  a  cause  of  rectal  disease,  820. 
Dichotomy,  posterior,  121. 
Dickinson,  2.53. 
Dietl,  7.59. 
Digital  examination,  35. 

technique,  .36. 
I>igitation,  exploratory,  .364. 
Dilatation  of  cervix,  ?>'>C,,  364,  421. 

as  a  cause  of  infection,  .302. 

clfctriflty  in,  7.30. 

for  aiitc-d''viMtions,  312. 

tochnlf|ue,  31.''.. 
Dilatation  of  nrctlira,  803. 

causes,  803. 

operations  for,  803. 
Dilator,  as  a  means  of    examination,  45. 

Goodell's,   40;   lllns.,   p.   40. 

Hegar's,   .309;   lllns.,   p,   .309. 


Dilator,   Reed's,   541;  illus.,   p.   541. 

urethral;  illus.,  p.  746. 
Diplococcus  pneumoniae,  486. 

in  Fallopian  tuljes,  486. 
Dlphallus,  120,  121. 
Diphtheria,  bacillus  of,  167. 
Diphtheria  of  external  genitalia,  179. 
diagnosis,  179. 
symptoms,  179. 
treatment,  179. 
Disease,  Raynaud's,  196. 
hypertrophic  and  hyperplastic,  of  puden- 
dum, 21.3, 
Diseases  of  women,  civilization  as  a  fac- 
tor, 6. 
general  etiology  of,  5. 
Indian  women,  6. 
prevalence,  5. 
systemic  causes,  9. 
Disorders,  pelvic,  865. 

nervous  symptoms  of,  865. 
Displacements    of,    Fallopian    tubes,    47.3, 
477. 
kidneys,  750. 
ovaries,  560. 

causes,  564. 
rectum,  817. 
uterus,  284. 
ante-deviations.   310. 
bimanual  examination  of,  38. 
classification,  285. 
etiology,  285. 
inversion,  324. 
pathology  of,  286. 
prolapse,   317. 
treatment,  288. 
vagina,  237. 
pathology,  238. 
symptoms,  238. 
treatment,  2.39. 
Distoma  haematobium,  infection,  180. . 
Dittrich,  481. 
Diverticula  of  urethra,  801. 

treatment,  802. 
Divulsiou  of  rectum,  846. 
Doderlein,  16,  164,  166,   170,   372,  490,   513, 

531. 
Doleris,  478,  .546,  600. 

Doran,  Alban,  422,  478,  628,  635,  670,  805. 
Dorsal  position,  33;  illus.,  3.3. 
Dorsett,  2.55. 
Double  uterus,  278. 

Douche,  intrauterine,  for  hemostasis,  425. 
vaginal,  33. 
apparatus  for,  .32. 
in  gonorrhoea,  169. 
infections  of  ovary,  581. 
malignant  diseases,  236. 
pruritus,  204. 
salpingitis,  .37,  .5.35. 
Douglas,  204,  285,  314,  0.30,  805. 
Doyen,  81,  418,  .528,  5.30,  .554,  555,  556,  557, 

558,  559. 
Doyen's  operation  of  hysterectomy,  .5.56. 
modifications.  567. 


874 


A  TEXT-BOOK  OF  GYNECOLOGY 


Doyen's  operation   of  hysterectomy,    Pry- 

or's  modification,   558. 
Drainage,  112,  115,  116. 

abdominal  incision,  112. 

abdomino-vaginal  incision,  544. 

after,  abdominal  section,  114. 
liysterectomy,  414. 
myomectomy,  410. 
ovariotomy,  644. 
salpingectomy,  553;  illus.,  553,  554. 

exploratory  incision  for,  543. 

inguinal  incision,  542. 

inguinal  vaginal  incision,  542. 

of  pelvic  abscess,  689. 

salpingitis,  540. 

tlirough-and-through,   544,   545. 

tubercular  peritonitis,  697. 

tube.  Reed's,  114;  illus.,  p.  115. 

Reed's    through-and-through,    544;    il- 
lus., p.  544. 

vaginal  puncture,  542;  illus.,  .542. 
Dranitzin,  123. 
Dressing,   for  abdominal  incision,  470. 

sterilization  of,  62. 
Dronius,  460. 
Drysdale,  606. 
Dsirne,  648. 
Dubois,  461. 
Ducrey,  183. 
Duct  of  Gartner,  671. 

of  Muller,  117,  118,  126. 

Wolflaan,  671. 
Dudley,  A.  Palmer,  97,  265,  294,  682,  683. 

685. 
Dudley,  E.  C,  32,  219,  282,  314,  730. 
Diihrssen,  235,  437,  441. 
Dujon,  245. 
Duke,  Alexander,  44. 
Dumesnil,  210. 
Dumont-Leloir.  .365,  .370. 
Dumont  forceps,  370. 
Duncan,  IMatthews,  189,  429,  682,  726. 
Dunlap,  633,  638. 
Dunn,  588. 
Dunning,  425. 
Duplay,  606. 
Dupuytren,  725. 
Dwight,  682. 
Dysentery,  838. 

as  a  cause  of  stricture,  838. 
Dysmenorrhcea,  130,  360. 

as  a  symptom  of  salpingitis,  502. 

effect  of  corsets,  729. 

etiology,  725. 

exercise  as  a  preventive,  729. 

medical  treatment,  731. 

membranous,   752;  illus.,  p.   732. 
causes,  732. 
symptoms,  733. 
treatment,  734. 

treatment  of,  728. 
Dyspepsia  as  a  cause  of  amenorrhoea,  722. 

Earle,  830. 

Ear,  menstruation  from,  736. 


Ebstein,  776. 

Ecchymosis  in  endometritis,  362. 
Echinococcous    infection    of,    broad    liga- 
ment, 690. 

uterus,  393. 
diagnosis,  394. 
liysterectomy  for,  395. 
pregnancy  in,  394. 
symptoms,  394. 
treatment,  395. 
Eckhard,  626. 

Ecraseur,  application  of,  424. 
Eckstein,  683. 

Ectopic    pregnancy,     see    Pregnancy,    ec- 
topic. 
Eczema  intertrigo,  191. 
Eczema  marginatum,  205. 
Eczema  rubrum,  197. 
Eczema  of  vulva,  196. 

acute,  196. 

chronic,  197. 

treatment,  197. 
Edebohls,  313,  527,  695,  752. 
Education  as  a  cause  of  disease  in  wom- 
en. 6. 
Edwards,  W.  A.,  123,  844. 
Ehrendorfer.  229,  801. 
Eiselberg,  52. 
Elder,  George,  122. 
Electric  forceps,  84;  illus.,  p.  84. 
Electricity,  apparatus,  539. 

as  a  therapeutic,  23. 

for  fibroid  tumours,  124. 

for  fibromyomata,  404. 

for  hemostasis,  83. 

for  menorrhagia,   719. 

for  pruritus  vulvae,  204. 

for  salpingitis,  539. 

in  dilatation  of  cervix,  730. 

in   uterine  dsplacements,   291. 

indications  for  use,  23. 
Electro-hemostasis,  83. 
Elephantiasis  of  vulva,  216. 

classification,  217. 

etiology,  219. 

histology,  218. 
Ellinger,  312. 
Eisner,  167,  179. 
Emanuel,  387. 
Emboli,  73. 
Embryology,  of  hymen,  131. 

of  parovarium,  670. 

of  vagina,  117. 
Emerich.  52. 

Emmet,  2,  4,  22,  144,  173,  262,  263,  267,  271, 
285,  306,  323,  324,  334,  339,  341,  342, 
349,  366,  391,  421,  422,  42.3,  725,  730, 
818. 
Emmet's  operation  for,  incomplete  lacera- 
tion of  perineum,  260. 
modifications,   265. 

prolapsus,  323. 
Emotion,  as  cause  of  menorrhagia,  714. 
Enchondromata  of,  rectum,  844. 

vulva,  223. 


INDEX 


875 


Endoeervix,  eversion  of,  335. 
Endometritis,  357;  lllus.,  p.  359. 

as  cause  of  dj'smenorrhoea,  360. 

cauterization  in,  366. 

cervix  in,  364. 

curettage  for,  313,  368. 

diagnosis  of,  364. 

discliarge  in,  363. 

ecctiymosis  in,  362. 

escliarotics  in,  365. 

etiology,  361,  362. 

exfoliative,  352. 

glands  in,  363. 

tiemorrhage  in,  363. 

hot-water  irrigation  for,  367. 

hypertrophic,  361. 

packing  for,  366. 

Reed's  treatment,  365. 

section,  illus.,  p.  352. 

steam  treatment,  366. 

symptoms,  363. 

tampon  for  diagnosis,  363. 

topical  remedies,  365. 

treatment,  365. 

tuberculous,  388. 
Endometrium,  function  of,  350. 

inflammation  of,  357. 

in  menstruation,  351. 

microscopic  anatomy  of,  350. 

secretion  of,  350. 
Endothelioma  of  ovary,  624. 
histology,   625. 
recurrence  of  626. 
section,   illus.,  625. 
types  of,  625. 

uterus,  434. 
origin,  435. 

vagina,  233. 
Engelmann,  22,  23,  680. 
Engorgements  of  liver,  as  a  cause  of  gen- 
ital disorders,  9. 
Enteroclysis,  77. 
Enucleation  of  myoma,  409. 

of  uterine  tumours,  420. 
technique,  421. 
Epispadias,  123;  illus.,   p.  124. 

treatment,  123. 
Epistaxis,  127. 
Epithelioma,  of  cervix,  386. 

resemblance  to  tuberculosis,  387. 

clitoris,  228;  illus.,  p.  229. 

kidney,  78.3. 
Epithelium  of  endometrium,  .351. 
reproduction  of,  370. 

of  tnl)al  mucosa,  489. 
hyiicrplasia  of,  522. 
Eppinger,  429. 
Ernst,  718. 
Erosion,  chanfrous,  185. 

sniierlicial,  185. 
iOrysipclas,  52. 

as  a  cause  of  genital  disorders,  9. 

of  external  genitalia,  177. 

syniptorns  of,  177. 

treatment  of,  178. 


Erythema,  etiology  of,  194. 

treatment,  195. 
Escharotics,   in  endometritis,  365. 
Escherich,  791. 

Eskimo,  menstruation  of,  700. 
Esmarch,  24. 
Esmarcli's   chloroform   inhaler,    94  ;  illus., 

p.  95. 
Ether,  administration  of,  90,  92. 

contraindications  for  use,  90. 

indications  for  use  of,  88. 

inhaler,  94. 

relation  to  bodily  temperature,  89. 

relative  safety  of,  88. 
Etheridge,  J.  H.,  446. 
Etiology  of,  diseases  of  women,  5. 

sterility,  141. 
Eversion  of  the  endoeervix,  335. 
Examination,     of    various    parts    of    the 
body,  47. 

auEcstliesia  in,  40,  92. 

bimanual,  37;  illus.,  p.  .37. 

digital,  35. 

gynecological,  30. 

instrumental,  42. 

of  blood,  49. 

of  external  genitals,  34. 

of  fseces,  48. 

of  Fallopian  tubes,  516. 

of  kidneys,  744. 

of  inverted  uterus,  326. 

of  menstrual  discharge,  48. 

of  nervous  system,  49. 

of  ovary,  632. 

of  prolapsus  uteri,  321. 

of  rectum,  808. 

of  urinary  apparatus,  744. 

of  urine,  47. 

of  uterine  displacement,  290. 

physical,  31,  744. 

rectal,  39. 

vaginal,  30. 
Excision  of  clitoris,  234;  illus..  p.  234,  235. 

of  rectum,  847. 
Excrescence,  masturbatory,  215. 
Exosmosis,  22. 

Exposure,  as  cause  of  shock,  72. 
External  genitalia,  34. 

development,  117. 

diseases  of  skin,  191. 

examination,  34. 

hypertrophic    and    hyperplastic    disease, 
213. 

infections  of,  163. 

injuries  of,  135. 
Extirpation  of  vagina,  2.3.5. 
Extract,  of  ovary,  21. 

supr.'ironal,  75. 

thyroid,  21. 
Extra-utorine      pregnancy,      see      Ectopic 
pregnancy. 

Eackler,  186. 

Firces,  examination  of,  48. 

Fainting,  7.3. 


876 


A  TEXT-BOOK   OF  GYNECOLOGY 


Falconiis,  Xicolai,  460. 

Fa  Ik,  22. 

Fallopiau  tubes,  absence  of,  473. 

accessory  tubes,  474. 

actinomycosis,  231. 

anatomy,  489. 

anomalies  of,   as  cause  of  ectopic  preg- 
nancy, 651. 

atresia,  cause,  495. 

bacillus  coli,  infection  of.  528. 

bacillus  tuberculosis  in,  486. 

bacteria  in  disease,  484. 

bacteria  in  health,  484. 

carcinomata  of,  48. 

chronic  salpingitis,  489. 
morbid  histology.  491. 

conservative  operations  in,  546. 

cystomata  of,  480. 

development,  473. 

defective    development,     473;    illus.,     p. 
474. 

displacements,  473,  477. 

diplococcus  pneumoniae  in,  486. 

fibromyomata  of,  481. 

gonococcous  infection  of,  512. 

hernia  of,  477. 

hydrosalpinx.  484. 

infections  of.  483.  512. 

infection,    relative    to    inflammation    of, 
487. 

irrigation.  .584. 

ligation  of,   in  Caesarean  section.  469. 

lipomata  of,  480. 

malformations,  473. 

manual  examination  of.  38. 

menstrual  function  of.  709. 

•'  mixed  infection  "  of,  486. 

neoplasms,  478,  481. 

origin,  117. 

ostia,  474;  illus.,  p.  475. 

papillomata  of,  478. 

pneumococcous  infection  of,  529. 

pyosalpinx,  486. 

radical  operations  on,  549. 

salpingitis,  acute,  489. 

salpingitis,  catarrhal,  489. 

salpingitis,  chronic,  486. 

saprophytic  infection  of,  530. 

sarcomata  of.  482. 

section,  salpingitis,  illus.,  pp.  491.  492. 

septic  vibrion  infection.  531. 

staphylococcous  infection  of,  5.30. 

streptococcous  infection  of,   516. 

structure  of  mucosa,  489. 

supernumerary.  474. 

Tait's  operation  for  removal  of,  551. 

tuberculosis  of,  519. 
Farmer,  463. 
Farnsworth,  436. 
Fat  embolism,  73. 
Fat,  subcutaneous,  retraction  of,  110,  113  : 

illus.,  p.  111. 
Fehleisen,  376. 
Fehling,  213,  376,  391,  606. 
Fehrenbatch,  Colonel  John,  61. 


Feinberg,  204. 

Fenger,  761,  764,  767. 

Ferguson,  307,  308. 

Ferguson's   operation   of   ventral   fixation, 

308;  illus.,  p.  309. 
Fernet,  520. 

Fever,  puerperal,  52,  376. 
bacteria  of,  376. 
curettage  in,  381. 
diagnosis,  381. 
endometrium  in,  377. 
hysterectomy  in,  383. 
irrigation  in,  382. 
lochia  in,  380. 
myometrium  in,  377. 
pathology  of,  376. 
perspiration  in,  380. 
respiration  in,  381. 
syphilis  in,  376. 
symptoms,  380. 
tampon  for,  382. 
temperature  curve,  380. 
treatment,  381. 
Fibrocystoma,  of  uterus  as  a  complication 

of  ovarian  tumours,  636. 
Filiroid,  recurrent,  435. 
Fibroid  tumours  of,  broad  ligament,  677. 
cervix,  420. 
Fallopian  tubes,  480. 
kidney,  781. 
ovary,  614:  illus.,  61.5. 
rectum,  843;  illus.,  843. 
uterus,  396. 
vagina,  226. 
vulva,  222. 
I'^ibroma  molluscum  of  vulva,  223. 
Fibromyomata,  classification,  397. 

degeneration  of.  299.  .399;  illus.,  401. 
Fibromyomata  of  broad  ligament,  677,  682.^ 
uterus,  396. 
diagnosis,  401. 
etiology,  397. 
hemorrhage,  401. 
histology  of,  398. 
hysterectomy  for,  404;  illus.,  405. 
interstitial,  398;  illus.,  402. 
intraligamentous,   398. 
pain,  401. 

pregnancy,  403;  illus.,  404. 
subserous,  398. 
treatment.  404. 
Fallopian  tubes,  480. 

origin.  480. 
vulva,  18.  222. 
Filters,  61. 
Fimbria    in    streptococcous    infection    of 

tubes,  517. 
Fischel,  W.,  670,  671,  672,  673. 
Fisclier,  245. 
Fischer,  J.,  21. 
Fissure,  anal,  820. 
diagnosis,  833. 
symptoms,  832. 
treatment,  833. 
Fistula,  faecal,  1.52,  831;  illus.,  151. 


INDEX 


877 


Fistula,   fsecal,   diagnosis,  835. 

symptoms,  S3o. 

treatment,  835. 
Fistulse,  urinary,  illus.,  344,  345. 

diagnosis  of,  141. 

etiology  of,  140. 

operations,  142,  155. 

prognosis,  142. 

symptoms,  141. 

treatment,  142. 

vesico-umbilical,  804. 
Fixation,  ventral,  of  uterus,  305. 

vagina,  303. 
Flaischlen,  610,  626. 

Flap-splitting  operation,  267;  illns.,  p.  207. 
Flexner,  .514. 
Floor,  pelvic,  250. 
Florence  solution,  158,  159. 
Foetal  uterus,  277. 

menstruation  from,  277. 

symptoms  of,  277. 

treatment  of,  277. 
Fcetus,  location  of,  465. 

manipulation  of,  467. 
Follicle,  hair,  198. 
Follicular  cysts  of  ovary,  illus.,  p.  598. 

development  of,  598. 

contents,  599. 

histology,  599. 
Folliculitis,  198. 

symptoms,  199. 

treatment,  199. 
Forceps,  Bozeman's  dressing,  illus.,  369. 

cervix,  370. 

dissecting,  illus.,  p.  448,  639. 

electric   (hemostasis),   84;  illus.,    p.   84. 

hemostatic,  80. 

hemostatic,  application  of,  107. 

mouse-toothed,  illus.,  p.  747. 

Pean's,  423;  illus.,   p.   422. 

pressure,  illus.,  p.  640. 

Pryor's  traction.  5.58. 

Reed's,  for  round  ligament,  300. 

serrated  cervix,  370. 

tongue,  95. 
Ford,  136. 
Fordyce,  129,  131. 
Foreign  bodies  in  bladder,  796. 

in  uterus,  348. 
Formula,  condylomata  treatment,  216. 

erythema,  treatment  of,  195. 

interti'igo,  treatment  of.  193. 

leucorrhoea,  treatment  of,  374. 

resorcin  salve,  194. 

Wilkinson's  ointment,  194. 
Fornia,  185. 

Foster,  Frank  P.,  3,  50,  56,  100. 
Fourchette,  see  Vulva. 
Fournior,  161,  392. 
Francke.  441. 
Frank,  294,  7.57. 

Friinkel,  180,  386,  .",87,  .599,  611. 
Franque,  386,  389,  4.'52,  4;;7,  575,  57(;. 
Freer,  805. 
Frcri'lis,  577. 


Freund,  21,  271,  .304,  394,  458. 

Freund,  W.  A.,  691. 

Freymuth,  166. 

Friedlander,  385,  175. 

Fritsch,  2.35,  241,  366,  556,  813. 

Froebel,  7. 

Frommel,  .529,  530,  574,  575. 

Frorieps,  389. 

Fuller,  692. 

Function  of  cervix,  350. 

of  endometrium,  351. 

of  pelvic  floor,  250,  254. 

of  vulvo-vaginal  gland,  243. 
Fused  kidney,  751. 
Fiitterer,  758. 

Gaither,  382. 
Galen,  1. 
Ganghoffer,  440. 

Gant,  823,  825,  826,  830,  831,  832,  838,  840, 
841,   842,   843,  844,   845,  847,   848,  851, 
852,  853. 
Gant's  clamp,  854. 
Gardien,  460. 
Gardiner,  647. 
Gartner,  248. 
Gartner's  duct,  671. 

cysts  of,  224. 
Gau,  382. 
Gau's  curette,  345;  illus.,  p.  .346. 

speculum,  44;  illus.,  p.  43. 
Gauze  for  drainage,  614. 
Gaylord,.  184,  647. 
Gebhard,  13,  4.30,  434,  611. 
Gehle.  .526. 
Gehrung,  726. 
Geil,  .389. 
Geist,  249. 
Gemmell,  702. 
Generative  organs  in  ovulation,  14. 

pathology,  12. 
Genital  glands,  117. 

groove,  117. 

tubercle,  117. 
Genitalia,    external,    aerogenous    infection 
of,  180. 

aphthae  of,  179. 

bacteriology  of,  16.3. 

cutaneous  diseases  of,  191. 

development  of,  117. 

diphtheria  of,  179. 

erysipelas  of,  178. 

gonorrhoea  of,  53,   166. 

infection  of,  16.3,  165. 

injuries  of,  156. 

neoplastic  changes,  18. 

parasites  of  skin,  205. 

syphilis  of,  17,  189. 

trophic  changes,  17. 

tulierculosis  of,  17. 
Geraldes,  670. 
fiei-iiiicidiil  iigeiits,  (!.'!,  170. 
Ciersuny,  12.3,  80.3. 

Gersuny's  opei'alioii    for   dilatntion  of  the 
urcllira,  80.3. 


878 


A  TEXT-BOOK   OF   GYNECOLOGY 


Gessner,  364. 

Grcstation,  relation  to  pathological  states, 

14. 
Giglio,  531. 
Gilliam,  604. 
Girode,  528,  530. 

Glands,  inguinal,  suppuration  of,  515. 
genital,  117. 

lymphatic,  removal  of,  452. 
sexual,  126. 

uterine,  dihitation  of,  361,  363. 
vulvo-vaginal,  170,  243;  illus.,  p.  243. 
carcinoma  of,  228. 
extirpation  of,  170. 
gonorrhcea  of,  167. 
Glans  of  clitoris,  118. 
G  leaves.  124,  783. 
Glenard's  disease,  757. 
Gloves,  rubber,  70,  295. 
Glycosuria,  as  a  cause  of  erythema,  194. 

at  menopause,  740. 
Goelet,  719. 
Geonner,  353. 
Gofife,  294,  301,  328,  681. 
Goglio,  387. 

Goldspohn,  68,  271,  298. 
Gonococcus,  53. 
as  a  cause  of  disease  in  women,  11. 
destructive  action,  374. 
means  of  diagnosis,  373. 
of  Neisser,  53,  163:  illus.,  p.  53. 
superinfection  with,  375. 
Gonococcous   infection   of,    external    geni- 
talia, .53,  166. 
course  of,  166. 
diagnosis,  167. 
pathology,  167. 
treatment,  168. 
Fallopian  tubes,  512. 
action  of  leucocytes,  513. 
bimanual  examination  in,  515. 
course  of,  512. 
desquamation  in,  513. 
discharge  in,  515. 
fimbriae  in,  513. 
location  of  gonococci,  513. 
pain  in,  515. 
symptoms,  515. 
inguinal  glands,  515. 
ovary,  569,  574. 
origin,  574. 
sclerosis  in,  574. 
symptoms,  580. 
results,  580. 
rectum,  826. 
etiology,  826. 
pathology,  827. 
treatment,  827. 
Skene's  glands,  245. 
uterus,  372. 
diagnosis,  373. 
etiology,  372. 
in  puerperium,  373. 
pathology,  373. 
secretion  in,  732. 


Gonococcous    infection    of    uterus,    symp- 
toms, 373. 
tampon  for,  375. 
treatment,  374. 

vulvo-vaginal  glands,  170. 
histology,  244. 
symptoms,  245. 
Gonorrhoea,  see  Gonococcous  infection. 
Gonzalez,  588. 

Goodell,  9,  46,  429,  313,  730,  681. 
Gordon,  S.  C,  4. 
Gortier,  686. 
Gottscbalk,  354,  627. 
Goulard,  196. 
Goulliund,  750. 
Goutil,  649. 

Graafian  follicle,  13,  14. 
Gram,  183,  487,  513. 
Griinicher,  232. 
Grape,  434. 

Grawitz,  115,  571,  785. 
Green,  473. 
Groove,  genital,  117. 
Guerin,  224. 
Guilbert.  2. 
Guillemeau,  461. 
Guillemain,  576. 
Gummata,  688. 

of  rectum,  829. 
Gunning,  7.34. 

Gusenthal,  Yon  Roguer,  565. 
Gusserow,  436,  460,  696,  671. 
Guyon,  528,  765,  786. 
Gynandria,  126. 

Gynecological  armamentarium,  27. 
Gynecology,  conservative,  4. 

definition,  1. 

etymology,  1. 

examination  in,  3. 

historical  resume,  1. 

nomenclature,  3. 

radical,  4. 

specialism  in,  2. 

therapeutics  of,  20. 

Habits,  personal,  as  a  cause  of  pelvic  dis- 
ease, 8. 

Haeckel,  230. 

Hages,  686. 

Hair  follicle,  198. 
anatomy  of,  198. 
infection  of,  199. 

Halbertsma,  391. 

Hall,  676,  677. 

Halle,  791. 

Halstead,  70. 

Hammarsten,  603,  606. 

Handfleld-Jones,  726,  727. 

Hands,  sterilization  of,  69. 

Hanks,  313,  403. 

Hannan,  442. 

Hare,  74,  88,  89,  93. 

Harris,  M.  L.,  251,  253,  273,  474,  754,  758, 
761,  763,  764,  776,  777,  782,  789,  791,^ 
796,  818. 


INDEX 


870 


Harris,  R.  P.,  100. 

Harris's    operations    for   deep    injuries   of 
pelvic  floor,  272. 
urine  segregator,  747;  illus.,   p.  748. 
Hart,  131. 

Hart,  Berry,  126,  131. 
Hartman,  528. 
Hassmer,  725. 
Hauser,  792. 
Haussman,  163. 
Hawkins,  676,  677. 
Head,  manipulation  of,  in  anaesthesia,  96. 

in  birth,  2.56. 
Heape,  Walter,  699,  708,  710. 
Heat,  hemostasis  by,  80. 

sterilization  by,  61. 

treatment  of  shock  by,  75. 
Hebra,  205. 
Hecker,  137. 
Hegar,  385,  388,  427,  520,  521,  524,  525,  526, 

527,  578,  584,  597,  632,  680,  681. 
Hegar's  dilator,  369. 
Heiberg,  627. 
Heidenhain,  205. 
Heil,  318. 
Heimbs,  389. 
Heineke,  761. 
Heinrichs,  623. 
Heitzmann,  210. 
Heller,  764. 

Hemangeiomata  of  pudendum,  221. 
Hematocele,  pudendal,  135,  136,  137,  138. 

rupture  of,  137. 

suppurating,  664. 
Hematocolpus,    119,    127,    130,    133;  illus., 

p.  127. 
Hematoma  of  ovary,  618. 

diagnosis,  618. 

pathology,  618. 

pudendum,  137. 
Hematonietra,  127,  133. 
Hematosalpinx,  127. 

etiology,  499. 

histology,  499. 
Hematuria,    as    a    symptom    of    renal    tu- 
mour, 786. 

renal  tuberculosis,  774. 

vesical  tumours,  799. 
Hemoptysis,  7.36. 
Hemorrhage,  73,  78. 

diagnosis  of,  73. 

follicular,  618. 

in  lacerated  cervix,  3.36. 

in  rape,  157.  I 

in  rupture  of  uterus,  535. 

intervillous,  654. 

interplacental,  654. 

symptoms,  78. 

tampon  for,  215. 

treatment  of,  79,  630. 

vulvar,  1.'{5. 
HcmoiThoJds,  capniai-y,  850. 

causes,  849. 

clamp-and-cautery  operation  for,  85.'i. 

clamp  for,  Illus.,  p.  854. 


Hemorrhoids,   cutaneous,   849. 
external,  849. 
injection  of,  851. 
internal,  850. 
ligation  of,  852. 
symptoms,  849. 
thrombotic,  849. 

treatment,  849,  851. 
venous,  851. 

Whitehead's  operation  for,  852. 
Hemostasis,  by,  cautery,  80. 

electric  forceps,  83. 

heat,  80. 

ligature,  86. 

pressure,  80. 

styptics,  79. 
Heunig,  124,  489. 
Henoch,   696. 
Henrotin,  4.30,  476,  655. 
Herbert,  C,  244. 
Hereford,  436. 
Heresco,  682,  787. 
Herman,  180,  392,  780. 
Hermaphroditism,  121,  124. 

bilateral,  562. 

pseudo,  125. 

unilateral,  562. 
Hernia,  inguinal,  298. 

of  Fallopian  tube,  477. 

of  ovary,  126,  564. 

post-operative,  104,  106. 
Herpes  progenitalis,  200. 

diagnosis,  201. 

etiology,  201. 

treatment,  202. 
Herzog,    13,    14,    15,    17,    18,    399,    400,    427, 
429,  433,   440,  476,   650,   651,   654,   656, 
658,  659,  660,  781,  782,  783. 
Heppner,  271,  562. 
Heterogeneity,  2. 
Hewitt,  Graily,  311,  726. 
Hewitt's  pessary,  311. 
Heyse,  590. 
Hildebrandt,  271,  697. 
Hippocrates,  1,  24,  437,  852. 
Hirschfeld,  781,  783. 
Hirst,  2.57. 
His,  427. 
Hislop,  394. 
Histology,  of  actite  salpingitis,  489. 

adenocarcinoma,  620. 

atrophy  of  vulva,  209. 

calcareous  tumours  of  ovary,  616. 

carcinoma  uteri,  439. 

chronic  salpingitis,  491. 

cysts  of  corpus  luteum,  600. 

cysts  of  vulvo-vaginal  glands,  247. 

dermoid  cysts,  611. 

ectopic  pregnancy,  616. 

endothelioma,  625. 

fibroma  of  ovary,  615. 

fil)roma  of  uterus,  398. 

follicular  cysts,  599. 

gonoi'rha'n,  166. 

hematosalpinx,  499. 


880 


A  TEXT-BOOK   OF   GYXECOLOGY 


Histology,    of   hypernephromata,    783. 

medullary  carcinoma.  619. 

melano-carcinoma,  231;  illiis.,  p.  231. 

ovarian  abscess.  14. 

papilary  cysts,  609. 

papilloma,  609. 

pseudo-cysts,  606. 

renal  adenomata,  782. 

renal  adenosarcomata,  783. 

renal  sarcoma,  782. 

sarcoma  of  Fallopian  tubes,  482. 

sarcoma  of  ovary,  682. 

sarcoma  of  kidney,  782. 

sarcoma  of  uterus,  433. 

sarcoma  of  vagina,  233. 

serous  cysts,  608. 

syncytioma  malignum,  427. 

sypliilis  of  broad  ligament.  690. 

tuberculous  peritoneum.  692. 

tuberculous  tubes,  521. 

tuberculous  ovary,  570. 

tuberculous  vagina,  172. 

tubo-ovarian  cyst,  576. 
Hofbauer,  390. 
Hoffmann,  549. 
Hofmann,  E.  V.,  157. 
Hofnieier,  351,  458. 
Hofmeister,  67,  08. 
Holder,  6. 

Holmes,  Oliver  Wendell.  87.  113.  178,  376. 
Horseshoe  kidney.  751. 
Hottentot  apron,  213. 
Howie.  703. 
Huguier,  189,  224. 
Hunter,  397. 

Hutchinson.  Jonathan.  4. 
Hydatid  of  Morgagni.  071. 
Hyde,  189. 

Hydrocele   of   round    ligament,    pathology, 
077. 

treatment.  677. 
Hydronephrosis,  see  Xephrydrosis. 
Hydrosalpinx,  calculus  in.  497. 

deHnition.  495. 

diagnosis,  505,  510. 

discharge  from.  505. 

distention  in.  496. 

etiology.  484. 

menstrual  disturbance  from,  505. 

pain  from.  505. 

pseudo-follicularis,  497. 

relation  to  pyosalpinx,  495. 

secretion  in.  497. 

symptoms,  .505. 

types.  497. 
Hydrops  tubse  profiuens.  497. 
Hymen,  absence  of,  35,  133. 

anomalies  of.  131.  133. 

atresia  of.  132. 

biforis.  130. 

bilamellatus,  133. 

cysts  of.  224. 

development  of,  118. 

double.  133. 

embryology  of,  131. 


Hymen,  laceration  of,  136,  157. 
malformations  of,  131. 
operation  on,  for  atresia,  133. 
puncture  of,  725. 
Hyperemia  of  bladder,  595. 
treatment,  796. 
ovary,  567. 
treatment,  568. 
Hypersesthesia,  801. 
Hypercatharsis.  101. 
Hypernephromata,  784;  illus.,  p.  785. 

histology  of,  785. 
Hyperplasia,  of  lymphatics,  688. 

pudendum,  213. 
Hypertrophy  of  cervix,  319. 
etiology,  335. 
clitoris,  126,  213. 
glands  of  uterus,  361. 
labia  minora.  124,  213. 
ovaries, 
pathology,  594. 
treatmenr,  595. 
prepuce,  220. 

operation.  218,  219. 
pudendum,  213. 
uterus, 

treatment,  393. 
vulva,  213. 
Hypnosis,  in  annesthesia,  98. 
Hypodermoclysis,  74,  70. 
Hypospadias.  118. 
operation  for,  122;  illus.,  p.  123. 
perineo-scrotal,  125;  illus.,  p.  125. 
Hysterectomy,  accidents  in,  415. 
classification  of,  405. 
complete,  see  Panhysterectomy, 
definition,  405. 
Doyen's,  5.56. 
electro,  456. 
advantages  of,  457. 
definition,  4.56. 
results,  4.59. 
technique.  456. 
hemorrhage  after,  415. 
supra-vaginal.  410. 
drainage  after,  414. 
hemostasis  in,  411,  413. 
instruments  for,  103,  412. 
technique,  412. 
vaginal,  419.  447. 
after-treatment,  452. 
angeiotribe  in,  81. 
cautery  in,  449. 
indications  for,  559. 
instruments  for,  103,  448. 
position  of  patient,  556. 
removal  of  ligatures,  452. 
technique,  448. 

technique.  Doyen's  operation,  556. 
treatment  of  adhesions,  557. 
treatment  of  glands,  453. 
Hysteria.  800. 

symptoms,  860. 
Hystero-myomectomy,  see  Myomectomy. 
Hysteroscope,   44;  illus.,   p.  45. 


INDEX 


881 


Ichthyosis  vulvae,  207. 
Ilio-coccygeus  muscle,  2ol. 
Ill,  3S2,  805. 
Immervvahr,  3.54. 
Incision,  exploratorj',  G37. 
Incision  for,  abdominal  section, 
closure  of,  109. 

direction  of,  105. 

general  observations  on,  107. 

inguinal,  106. 

location  of,  103. 

lumliocostal,  107. 

lumbo-iliac,  107. 

oblique  subcostal,  106. 

oblique  ventral,  107. 

transverse  suprapubic,  106. 

transverse  umbilical,  106. 

vertical  median,  105. 
drainage, 

abdominal,  544,  689. 

abdominal  vaginal,  544. 

dilator  for,   541. 

inguinal,  542. 

inguino-vaginal,  542. 

rectal,  546. 

vaginal,  541. 
nephrectomy,  787. 
ovariotomy,  641. 
perineorrhaphy,  2.58. 
Incontinence  of  urine,  134,  141. 
Indian  women,  menstrual  habits  of,  6. 
Infantile  uterus,  277. 

treatment,  280. 
Infantilism,  120. 
Infections,  of,  bladder, 
as  a  symptom  of  rape,  158. 
puerperal,  10,  18,  165. 
etiology,  178. 
Infections,  of  bladder,  790. 

bacteriology  of,  791. 

diagnosis,  793. 

etiology,  790. 

pathology,  792. 

symptoms,  793. 

treatment,  794. 
broad  ligament,  688. 

course  of,  163. 

etiology,  688. 

pathology,  088. 
external  genitalia,  163. 

mixed,  165. 

course  of,  163. 
Fallopian  tubes,  483. 

course  of,  .5.'{2. 

douche  in,  5.V>. 

hygienic  treatment,  5.35. 

libi'ration  of  pus,  534. 

local  treatment,  537. 

massage  for,  .5.38. 

medicinal  treatment,  5.36. 

prognosis,  ,533. 

ra(1ical  ti'calnjent,  540. 

relation  lo  Inflammation,  487. 

ruj)ture  In,  5.34. 

symptoms,  501. 

57 


Infections  of  Fallopian  tubes,   treatment, 
5.32. 

tampon  for,  537. 
hair  follicle,  199. 
kidneys,  768. 

bacteria  of,  769. 

diagnosis,  770. 

etiology,  768. 

pathology,  770. 

treatment,  772. 

urination  in,  771. 
lacerated  cervix,  3.37. 
lymphatics,  392,  395. 
ovary,  567. 

conservative  treatment,  .582. 

mortality,  579. 

natural  termination,  579. 

opium  in,  581. 

radical  treatment,  584. 

results  of  conservative  treatment,  583. 

palliative  treatment,  581. 

vaginal  douche  in,  581. 
peritoneum,  115,  688. 
pudendal  hematocele,  136. 
rectum,  824. 

diagnosis,  824. 

prognosis,  825. 

results,  822. 

symptoms,  824. 

treatment,  825. 
uterus,   16,   350,   .3.57,   372. 

endometrium  in,  3.57. 

etiology,  362. 

mixed,  .358. 

myometrium,  3-58. 

specific,  357. 

treatment,  365. 
vagina,  16,  163,  180. 
vulva,  16.3. 

vulvo-vaginal  gland,  243,  248. 
Inflammation  of,    bladder,   790. 
Fallopian  tubes,  487. 
ovary,  567. 
rectum,  424. 
uterus.  358. 
vagina,  163. 
vulva,  15,  153. 
vulvo-vaginal  gland,  244. 
Infusion,  intravenous,  77. 
subcutaneous,  76. 
rectal,  77. 
Inguinal  hernia,  298. 

incision,  107. 
Inguihodynia,  862. 
Inhaler, 
chloroform,  94. 
ether,  92. 

mixed  vapours,  94. 
Injection, 
cocaine,  97. 

treat  nieiit  of  hemorrhoids,  851.  ' 
Injuries  of,  hymen,  157. 
pelvic  floor,  2.53,  271. 
perineum,  162. 
rectum,  153. 


882 


A  TEXT-BOOK   OF   GYNECOLOGY 


Injuries,   of  pudendum,   136, 

uterus,  162,  331. 

vagina,  135,  139. 

vulva,  135,  136,  157,  162. 
Instrumental  examination,  42. 
Instruments  for,  abdominal  section,  103. 

Csesarean  section,  465. 

fistula  operations,  145. 

ovariotomy,  639. 

perineorrliaptiy,  259. 

supra-vaginal  tiysterectomy,  412. 

trachelorrhaphy,  338. 

vaginal  hysterectomy,  448. 
Instruments,  sterilization  of,  66. 
Intercourse,  sexual,  injuries  from,  136. 
Intercutaneous  suture,  110;  illus.,  p.  110. 
Intertrigo,  vulvar,  191. 

diagnosis,  192. 

etiology,  191. 

pathology,  192. 

treatment,  193. 
Intravenous  infusion,  77. 
Inversion  of  uterus,  324. 

acute,  327. 

chronic,  328. 

diagnosis,  326. 

etiology,  324. 

examination,  326. 

pathology,  327. 

surgical  treatment,  329. 

symptoms,  326. 

tampon  for,  329. 
Irion,  702. 
Irrigation,  in  gonorrhoea,  170. 

in  puerperal  fever,  382. 

of  Fallopian  tubes,  384. 
Israel,  764. 

Ischio-coccygeus  muscle,  251. 
Ivanhoff,  25. 

Jilcksch,  576. 

Jacobi,  781. 

Jacobs,  366,  458,  556,  576. 

Jacobson,  373. 

Jadassohn,  375. 

Jaennel,  819. 

Jaksch,  48. 

James,  Alexander,  127. 

Jameson,  195. 

Jan,  119. 

Jani,  388,  520,  576. 

Janni,  683. 

Jans,  .521,  692. 

Jenks,  21. 

Jevonsky,  209. 

Johnson,  Joseph  Taber,  641,  642,  644. 

Johnstone,  A.  W.,  585. 

Jones,  A.  P.,  327. 

Jones,   George  E.,   313,   338,   382,  421,   425, 

433,  448. 
Jones,  H.  C,  721. 
Jones,  Macnaughton,  308,  428,  736. 
Jones,  Mary  Dixon,  8. 
Jones's  speculum,  370;  illus.,  p.  370. 
Jonesco,  310. 


Jouin,  21. 
Jung,  233. 

Kahlden,  435- 
Kaltenbach,  680,  681. 
Kalustow,  233. 
Kangaroo  tendon,  68. 
Karagan,  171,  172. 
Karevi'ski,  163. 
Katz,  694. 
Kaufmann,  387. 
Keely,  779. 
Keen,  808. 

Kehrer,  163,  278,  329,  377. 
Keith,  SO,  638,  680. 

Kelly,  171,  175,  241,  279,  306,  389,  391,  548,. 
Oil,   635,  671,  672,  678,  680,  694,  746,. 
772,  779,  797. 
Kelynack,  781. 
Kerley,  737. 
Kholmogoroff,  204. 
Kidney,  absence  of,  749. 

adenomata  of,  782. 

adenosarcoma  of,  783. 

angeiomata  of,  781. 

anomalies  of  form,  751. 
location,  750. 
numbers,  749. 

cystadenoma  of,  782. 

epithelioma  of,  783. 

examination  of,  744. 

fibromata  of,  781. 

fused,  751. 

horseshoe,  751. 

infections  of,  768. 

liporaata,  781. 

movable,  752. 

operations  on,  787. 

palpation  of,  40. 

sarcoma  of,  781. 

tuberculosis  of,  772. 

tumours  of,  780. 
Kiefer,  294. 
King,  538. 
Kirck,  330. 
Kisch,  7.39. 
Kitasato,  ISO. 
Kivisch,  480,  481,  525,  670. 
Klebs,  179,  495,  576,  609,  692. 
Klein,  2.3.3,  702. 
Kleinschmidt,  435. 
Kleiuwachter,  68.3,  733. 
Klob,  495,  678,  683. 
Klotz,  294. 
Knauer,  525. 

Knee-chest  posture,  34,  291;  illus.,  p.  34. 
Knife,  Newman's,  339. 

canaliculus,  248. 
Knot,  Stafford.shire,  552. 
Kobelt,  670. 
Kobelt's  tubes,  671. 

cyst  of,  illus.,  p.  475. 
Koch,  55.  172,  180,  697,  830. 
Kocher,  70,  105,  234. 
Koeberie,  2,  81,  306,  407,  638. 


INDEX 


883 


Kolisko,  232. 

Konig,  G18,  787,  789. 

Kneftning,  183. 

Krajewski,  123. 

Kraska's  operation,  848. 

Kraurosis  vulvae,  207;  illus.,  p.  208. 

diagnosis,  210. 

etiology,  208. 

histology,  209. 

macroscopic  appearance,  207. 

treatment,  210. 
Kretschmer,  17. 
Krogius,  791,  792. 
Kronauer,  137. 
Kronig,  16,  70,  165,  373,  486. 
Kube,  475. 
Kuehne,  587,  658. 
Kumpf,  759. 

Kuster,  281,  282,  752,  754,  767. 
Kiistner,  318,  320. 
Kuttner,  753. 

Labadie-Lagrave,  518. 
Labia,  adhesions  of,  119,  120,  212. 
circulation  of,  221. 
hypertrophy  of,  213. 
malformations  of,  124. 
neoplasms  of,  see  Vulva. 
Lacassagne's  schedule,  159. 
Laceration,  of,  cervix,  334. 

classification,  337. 

complication,  337. 

hemorrhage,  336. 

infection  in,  337. 

operations  for,  338. 

pathology  of,  334. 

symptoms  of,  385. 

treatment,  337. 
perineum,  253. 

classification,  255. 

complete,  illus.,  p.  266. 
operations  for,  267. 

Harris's    operation    for    deep    injuries, 
272. 

immediate  operation  for,  258. 

incomplete,  260. 
Emmet's  operation,  260. 

Reed's  suture,  263. 

prevention  of,  256. 
La  grippe,  as  cause  of  genital  disorders,  9. 
Lair,  2. 

Laminated  suture,  109. 
Landau,  497,  525,  558,  755,  763. 
Landon,  302. 
Langhans,  656. 
Lannelongue,  808. 

Laparotomy,  see  Abdominal  section. 
Laser,  166. 
Lassar,  195. 
Lassar's  paste,  200. 
Law  of  Metschnikoff,  60. 
Law  of  Wyssakovil.Kch,  60. 
Lawrence,  562,  708. 
Lawrle,  94,  95. 
Le  Bee,  558. 


Ivebedeff,  435. 

Le  Cat,  120. 

Lebert,  385. 

Le  Fort,  271. 

Legueu,  756. 

Leick,  179. 

Leiomyoma  of  broad  ligament,  677. 

Lembert,  333. 

Lemhoff,  753. 

Leopold,  463.  624,  626,  638,  710. 

Lermoyez,  7.36. 

Lesion,  tubercular,  172. 

anatomy  of,  176. 
L'esthiomene,  171. 
Letulle,  797. 
Leucocytosis,  49. 
Leucoplakia,  228. 
Leucorrhoea,  176. 
Levator-ani  muscle,  252,  253. 

restoration  of,  271. 
Levret,  460. 
Levy,  180. 
Lewin,  201,  791. 
Lewis,  783. 

Libido  sesualis  after  oophorectomy,  588. 
Liborius,  531. 

Ligament,     broad,     aneurismal    varix    of, 
682. 
cysts  of,  67. 
infection  of,  688. 
neoplasms  of,  669. 
parasitic  infection  of,  690. 
phleboliths  in,  682. 
pyogenic  infection  of,  682. 
suppuration  in,  689. 
tuberculosis  of,  691. 
varicocele  of,  682. 
Ligament,     round,    dermoid    tumours    of, 
681. 
flbromyomata  of,  682. 
hydrocele  of,  677. 
in  uterine  displacements,  287. 
shortening  of,  294. 
Alexander's  operation,  294. 
Byford's  operation,  302. 
Goffe's  operation,  301. 
Mann's  operation,  299. 
Ligature,  catgut,  67. 
hemostasis  with,  86. 
kangaroo  tendon,  68. 
operation  for  hemorrhoids,   852. 
silk,  86. 

sterilization  of,  66. 
Lipomata,  of  broad  ligament,  677. 
Fallopian  tubes,  480. 
kidney,  781. 
rectum,  842. 
vulva,  223. 
Lister,  2,  50,  67. 
Liszt,  255. 

liitliokelyphopsedion,  655. 
Lil  liokclyfilios,  655. 
LilliopfTMlion,  655. 
Litten,  617. 
Lizars,  638. 


884 


A   TEXT-BOOK   OF   GYNECOLOGY 


Lochia,  bacteriology  of,  166. 

LocliC,  76. 

Locliett,  70. 

Loeffler,  179. 

Loewentlial,  706,  711. 

Lohlein,  289,  352. 

Lomer,  .353. 

Loops,  Pfliiger's,  671. 

Lopez,  703. 

Lotion,  Goulard's,  196. 

Louse,  body,  206. 

Lubricant,  for  vaginal  examination,  32. 

Ludwig,  332. 

Lumbocostal  incision,  107. 

Lumbo-iliac  incision,  107. 

Lupus  vulvae,  171. 

Luschka,  814. 

Lusk,  331,  463,  470. 

Luther,  574. 

Lymphadenitis,  392,  690. 

Lyuiphangeiitis,  690. 

Lymphangeioma   cystomatosum   of  ovary, 

624. 
Lymphangeiomata,  217. 
Lymphangeiosarcoma  of  ovary,  624. 
Lymphatics,  hyperplasia  of,  688. 

infection  of,  377,  392,  395. 

uterine,  351. 
Lymphorrha?a,  219. 

Maas,  776. 

Macacus  rhesus,  menstruation  of,  699. 

ovulation  of,  710. 
Mackenzie,  392. 
Mackenrodt,  249,  304. 
MacNeven,  393,  394. 
Maculse,   gonorrhcese,  245. 
Madlener,  389,  378. 
Madleur,  373. 

Magill,  513,  517,  518,  528,  529,  530. 
Maier,  521. 

Malaria  as  a  cause  of  menorrhagia,  714. 
Male,  hypospadiac,  125. 
Malformations  of  anus,  806. 

clitoris,  124. 

Fallopian  tubes,  473. 

hymen,  131. 

kidney,  749. 

labia,  124. 

ovary,  560. 

rectum,  124. 
prognosis,   807. 
symptoms,  807. 
varieties,  806. 

round  ligament,  298. 

ureters,  760. 

uterus,  classification,  274. 
etiology,  275. 
treatment,  280. 

vagina,  126. 

vestibular  band,  134. 

vulva,  118. 
Malins,  E.,  683,  685. 
Malpighian  layer,  215. 
Malthus,  10. 


Mandl,  13. 

Mann,  288,  289,  297,  299,  300,  301,  303,  304, 

306,  314,  324,  429,  564,  678. 
Mansfield,  460. 
Manton,  721. 
Marchand,  187,  428,  610. 
Marshall,  Balfour,  230. 

Martin,  A.,  114,  148,  211,  249,  257,  271,  304, 
366,   368,  441,  480,   482,   493,  495,   499, 
524,  525,   526,  570,   575,   578,   583,   589, 
638,  680,  C81,  781,  810,  811,  812,  835. 
Martin,  Christopher,  126,  706,  738. 
Martin's  curette,  368. 
Massage,  abdominal,  24. 

pelvic,  25,  538. 

position  of  patient,  538. 

technique,  538. 

treatment  of  uterine  displacement,  291. 

treatment  of  movable  kidney,  759. 
Massen,  476. 
Massey,  726. 
Massin,  362. 
Masturbation,  as  cause  of  disease,  9. 

etiology,  212. 

evidences  of,  160. 

excrescences  from,  215. 

labia  minora  in,  35. 
Matas,  807,  808. 
Matthews,  97,  386,  854. 
Mauriceau,  460,  461. 
Mayer,  W.,  432,  521. 
McDowell,  Ephraim,  2,  638,  639. 
McParland.  434. 
McLaury,  703. 
McMurrick,  751. 
McMurtry,    L.    S.,   263,   351,   403,   458,   663, 

666. 
Meadows,  749. 
Meatus  urinarius,  230. 

melanosarcoma  of,  230. 
Mechanism  of  prolapsus  uteri,  318. 
Medication,   general,  20. 

local,  22. 
Melano-carciuoma  of  vulva,  231. 
Melanosarcoma  of  vulva,  229. 

histology  of,  231. 

of  meatus  urinarius,  230. 
Melchoir,  791,  792. 
Melier,  2. 

Membrane,  uterine,  reproduction  of,  370. 
Menciere,  565,  566. 
Menge,  16,  353,  354,  487,  490,  495,  496,  521, 

530,  684,  685,  686,  687. 
Menopause,  203. 

age  of  occurrence,  738. 

carcinoma  at,  740. 

effect  on  heart,  740. 
on  ovaries,  738. 
on  uterus,  738. 

glycosuria  at,  740. 

inducement  of,  584. 

mental  condition  at,  741. 

metrorrhagia  at,  739. 

oophorectomy  at,  587. 

tachycardia  at,  740. 


INDEX 


885 


Menopause,   treatment   of  associated   con 

ditions,  742. 
Menorrhagia,  causes,  714. 
complications,  717. 
definition,  714. 
local  causes,  714. 
pelvic  causes,  715. 
rectal  complications,  717. 
systemic  causes,  714. 
tampon  for,  716. 
treatment,  537,  716. 
uterus  in,  715. 
Menses,  cessation  of,  738. 
examination  of,  48. 
retention  of,  282,  723. 
suppression  of,  706. 
symptoms  of  retention,  723. 
Menstruation,  absence  of,  720. 
arrest  of,  585. 

ciiaracter  of  discharge,  705. 
cycle  of,  704. 
disorders  of,  714. 
disturbances  of,  764. 
effect  of  general  systemic  diseases,  714. 
endometrium  in,  351. 
Fallopian  tubes  in,  709. 
from,  bicornate  uterus,  278. 
cervix,  735. 
ear,  736. 

infantile  uterus,  280. 
nsevus,  737. 
nose,  736. 

septate  uterus,  277. 
stomach,  736. 
hygiene  of,  712. 
in  atrophy  of  ovaries,  593. 
in  cirrhosis  of  ovaries,  593. 
inducing  cause,  706. 
ectopic  pregnancy,  661. 
ovarian  disease,  632. 
tubal  tuberculosis,  526. 
normal,  699. 

of,   domestic  animals,  699. 
Eskimo,  700. 
Indian  women,  6. 
Macacus  rhesus,  699. 
savages,  699. 
Semnopithecus,  699. 
students,  8. 
ovaries  in,  709. 
pain  in,  725. 
persistence  of,  588. 
precocious,  701. 
profuse,  719. 

fiuuntity  of  discharge,  704. 
relation  to,  conception,  711. 
ovulation,  710. 
piitliological  state,  12. 
time  of  appearance,  701. 
uterus  in,  ].'5,  708. 
vicarious,  735. 
white,  705. 
Mesenteric  cysts,  635. 

Metaljolism,   effect  on  oophorectomy,   589. 
Metastasis,  2:51,  621. 


Metastasis,  causes,  610. 
from  carcinoma  uteri,  481. 
from  syncytioma  malignum,  429. 
Metritis,  358. 
as  a  cause  of  dysmenorrhcea,  727. 
as  a  cause  of  menorrhagia,  715. 
classification,  358. 
diagnosis,  364. 
pathology,  359. 

Reed's  method  of  treatment,  365. 
symptoms,  363. 
treatment,  365. 
Metrorrhagia,  as  a  symptom  of  carcinoma, 
720. 
at  menopause,  729. 
etiology,  719. 
treatment,  720. 
Metrostaxis,   post-operative,   587. 
Metschnikoff,  60. 
Meyer,  253,  391. 
Micrococcus  gonorrhoese,  52. 
Mikulicz,  70,  83,  761. 
Miller,  44. 

Millikin,  Dan,  699,  702,  704,  705,  706. 
Miner,  680. 
Minor,  643. 

Mirror,  proctoscopic,  815. 
Mitchell,  H.   W.,  720. 
Mittelschmerz,  277. 
Mittermaier,  349. 

Mixed  vapours  for  anaesthesia,  93. 
Molluscum  pendulum  of  vulva,  223. 
Monclaire,  458. 
Montgomery,  257,  G47. 
Monti,  178,  376. 
Moostakoff,  120. 
Morax,  513,  528,  530. 
Morcellement,  forceps  for,  423. 
hemorrhage  in,  423. 
Pean's  method,  423. 
technique,  422. 
treatment  of  pedicle,  422. 
uterine  tumours,  420. 
Morgagni,  594. 

hydatid  of,  671. 
Morris,  211,  212,  695. 
Morse,  783. 
Mosetig,  von,  24. 
Mosler,  521,  575,  692. 
Mouth  gag,  95. 
Movable  kidney,  752. 
adhesions  of,  757. 
as  a  cause  of  nephrydrosis,  763. 
etiology,  752. 
examination  of,  752. 
gastric  symptoms,  758. 
indications  for  operation,  760. 
massage  for,  7.59. 
mechanical  influences,  754. 
operations  for,  760. 
pain  In,  758. 

pathologic  anatomy  of,  755. 
supporlor  for,  759. 
ireatmont,  palliative,  759. 
Movement  of  uterus,  285. 


A  TEXT-BOOK  OF  GYNECOLOGY 


Mucosa,   tubal,   in  streptococcic  infection, 
517. 

in  tuberculosis,  524. 

structure  of,  489. 
Mucosa,  uterine,  in  endometritis,  362. 

tuberculosis,  389. 
Miiller,  9,  131,  230,  235,  303,  362,  476,  556, 

779. 
Miillerian  vagina,  126,  127. 
Muller's  duct,  117,  118. 
Munclimeier,  458. 
Munde,  257,  366,  647,  678,  679,  734. 
Miioster,  525. 
Muret,  130. 
Muscatello,  115. 
Muscles  of  pelvic  floor,  250. 
Museus,  421. 
Myomata  of  bladder,  799. 

broad  ligament,  677. 

rectum,  844. 

uterus,  396,  503. 

vulva,  222. 
Myomectomy,  404,  407. 

definitiou,  404. 

drainage  after,  410. 

indications,  407. 

pregnancy  after,  408. 

technique,  407. 

treatment  of  pedicle,  407. 
Myometrium, 

inflammation  of,  358. 

in  puerperal  fever,  377. 

microscopic  anatomy  of,  352. 
Myomotomy,  vaginal,  420. 
Myxomata  of  vulva,  223. 
Myxosarcoma  of  vulva,  229. 

Naegele,  710. 
Nagel,  126,  561,  599. 
Naplieys,  6. 
Napier,  707,  738. 
Necrosis,  110. 
Needle,  aneurismal,  452. 
holder,  450 
Holmes's,  113. 
Reed's  curved,  339. 
Neisser,  53,  165,  167,  373,  374,  827,  166. 
Neisser,  gonococcus  of,  53. 
Neoplasms  of,  bladder,  798. 

diagnosis  of,  799. 

symptoms  of,  799. 

treatment,  800. 
broad  ligament,  carcinoma,  686. 

cysts,  670. 

dermoids,  6. 

fibromata,  677. 

lipomata.  677. 

myomata,  677. 

sarcoma,  686. 
Tallopian  tubes,  478. 

adenosarcomata,  783. 

carcinoma,  481. 

cystomata,  480. 

flbromyomata,  481. 

lipomata,  480. 


Neoplasms,    of    Fallopian    tubes,    papillo- 
mata,   478. 
sarcoma,  482. 
kidneys,  780. 
diagnosis,  785. 
fibromata,  781. 
hypernephromata,  784. 
involvement  of  ureter,  786. 
pain  from,  786. 
sarcoma,  781. 
symptoms,  785. 
treatment,  787. 
ovary,  benign  cysts,  597. 
bimanual  examination  of,  632. 
carcinoma,  619. 
complications  of,  627. 

adhesions,  031. 

albuminuria,  631. 

ascites,  630,  635. 

echinococcous  cyst,  635. 

flbrocystoma  of  uterus,  636. 

mesenteric  cysts,  635. 

nephrydrosis,  635. 

phantom  tumour,  636. 

pregnancy,  627,  634. 

rupture  of  tumour,  631. 

torsion  of  pedicle,  628. 
cysto-adenoma,  18. 
diagnosis,  633. 
effect  on  menstruation,  632. 
endothelioma,  624. 
hematoma,  618. 
palpation  of,  633. 
sarcoma,  622. 
solid  tumours,  614. 
symptoms,  503,  632. 
treatment,  637. 
pudendum,   benign,  221. 
carcinomata,  227. 
enchondromata,  223. 
fibromata,  222. 
fibromyomata,  18. 
lipomata,  223. 
malignant,  221,  227. 
melano-carciuomata,  321. 
myomata,  222. 
myxomata,  223. 
sarcoma,  230. 
sarcomata,  229. 
treatment,  233. 
varices,  221. 
uterus,  adenoma,  429. 
benign,  397. 
carcinoma,  437. 
etiology,  396. 
flbromyomata,  326. 
malignant,  426. 
sarcomata,  432. 
syncytioma  malignum,  426. 
urethra,  carcinoma,  801. 
caruncle,  80. 
melanosarcoma,  230. 
sarcoma,   801. 
vagina,  benign,  224. 
carcinomata,  233. 


INDEX 


887 


Neoplasms,  of  vagina,   cysts,  224. 
fibromata,  22G. 
malignant,  231. 
polypi,    226. 
sarcomata,  231. 
treatment,  226. 

vulva,  see  Neoplasms  of  pudendum. 

vulvo-vaginal  gland,  247. 
carcinoma,  249. 
cysts,  247. 
treatment,  248. 
Neoplastic  changes  in  genitalia,  18. 
Nephrectomy,  767. 

clamp  for,  789. 

technique,  789. 

treatment  of  pedicle,  789. 

treatment  of  ureter,  789.     , 
Nephritis,  as  a  cause  of  menorrhagia,  714. 
Nephrocystosis,  definition,  762. 

classification,  762. 
Nephropexj',  technique,  788. 
Nephropyelitis,  768. 
Nephropyosis,  766,  768. 
Nephrorrhaphy,  788. 
Nephrotomy,  767. 

hemorrhage  in,  788. 

technique,  788. 
Nephrydrosis,  acquired,  763. 

as    a    complication    of    ovarian    tumour, 
635. 

aspiration  in,  767. 

causes  of,  762. 

congenital,  762. 

diagnosis  of,  765. 

intermittent,  765. 

nephrectomy  for,  767. 

nephrotomy  for,  767. 

partial,  764. 

pathological  changes,  763. 

symptoms,  765. 

treatment,  766. 
Nerve  derangements,  120. 
Nervous  complications  in  gynecology,  856. 
Nervous    symptoms    of    pelvic    disorders, 

865. 
Nervous  system,  examination  of,  49. 
Netter,  51. 

Neugebauer,  120,  133,  224,  329,  348. 
Neuralgia  of  rectum,  820. 
Neurasthenia,  856. 

as  a  cause  of  genital  disorders,  9. 

symjjtoms,  856. 
Neuromata  of  vulva,  223. 
Neuroses,  from  oophoritis,  580. 

operations  for,  864. 
Neurosis,  fatigue,  856. 
Newman,  339,  849. 
Newman's  nngeiotribe,  81. 

volsella,  338. 
Nicolle,  513,  529. 
Nidus  perlniei,  251. 
Nlefer,  Jacob,  460. 
NIetort,  :',46. 
Nll5!<-,  717. 
NoIjIi',   Ocorgo  II.,   443,   444. 


Nodule,  indurated,  186. 

Noeggerath,  2,  11,  166. 

Nolen,  608. 

Noma  of  vulva,  167. 

Nomenclature,  of  gynecology,  3. 

Normal  salt  solution,  74,  75. 

Nose,  menstruation  from,  736. 

Nott,  365. 

Nott's  speculum,  44. 

Nourse,  282. 

Nuck,  298,  564,  677. 

Numa,  175,  183. 

Nurse,  requirements  of,  63. 

Nussbaum,  67. 

Nuttall,  54,  180. 

Nympha-,  see  Vulva. 

Obolonsky,  562. 

Obturator  coccj^geus  muscle,  250. 
Occlusion  of  cervical  canal,  279. 
Occupation,  as  a  cause  of  disease,  8. 

rectal  disease,  821. 

uterine  displacement,  286. 
Oildema  of  vulva,  195. 

treatment,  196. 
Ohmann,  210. 
Oidium  albicans,  167. 
Ointment,  Wilkinson's,  194. 

Wilson's,  193,  200. 
Oligochromsemia,  49. 
Oliver,  429. 

Olshausen,  209,  235,  458,  482,  598,  611,  624, 
647,  648,   671,  672,   673,  674,  676,   679, 
680,  681,  763. 
Omentum,  adhesions  of,  642. 

laceration  of,  643. 

tuberculosis  of,  693. 
Oneida  community,  9. 
Oophorectomy,  584. 

effect  on,  constitutional  condition,  587. 
general  metabolism,  589. 
intrapelvic  conditions,  590. 
libido  sexualis,  588. 
menopause,  587. 
menstruation,  587. 
sexual  function,  587. 

history,  584. 

indications,  584. 

manipulation  of  tubes,  585. 

metrostaxis  after,  587. 

mortality,  586. 

secondary  effects,  587. 

technique,  585. 

treatment  of  pedicle,  585. 

unilateral,  585. 
Oophoritis,  acute,  .568. 

as  cause  of  dysmenorrhcea,  728. 

chronic,  569. 

etiology,  569. 

histology,  .569,  .580. 

tu))erculous,  575. 
Operating  room,  64. 
Operating  tabic,  improvised,  64. 
Opium,  in  infection  of  ovary,  581, 
Oppenheim,  176. 


A  TEXT-BOOK   OF  GYNECOLOGY 


Orgasm,  sexual,  in  bimanual  examination, 

39. 
Ortlimann,  209,  210,  303,  304,  478,  481,  525, 

600. 
Os,   pin-liole,  283. 
Osiander,  447. 
Osier,  327,  692,  696. 
Osteomalacia,  590. 
Ostia,  accessory,  474. 

relation  to  ectopic  pregnancy,  476. 
Otroschkevitch,  739. 
Ott,  435,  707. 
Ovarian  abscess,  histology,  514. 

bacteriology,   514. 
Ovarian  extract,  21. 
Ovariotomy,  638. 
abdominal  incision,  641. 
accidents  in,  646. 
after-treatment,  645. 
closure  of  incision,  644. 
drainage  after,  644. 
dressing,  644. 
during  pregnancy,  647. 
emptying  of  cyst,  641. 
history,  638. 
incomplete,  646. 
indications,  639. 
instruments,  639. 
ligature  material,  642. 
mortality  from,  646. 
peritoneal  incision,  641. 
protection  of  intestines,   illus.,  p.  108. 
technique,  639. 
toilet  of  peritoneum,  643. 
treatment  of  adhesions,   642. 
treatment  of  pedicle,  642. 
Ovary,  absence  of,  560. 
accessory,  501. 
at  menopause,  738. 
atrophy  of,  592. 
bacillus  coli  infection  of,  575. 
bacteria  of,  570. 
bimanual  examination  of,  38. 
calcification  in,  017. 
cirrhosis  of,  593. 
coexistence  with  testicles,  562. 
conservative  operation  on,  582. 
constricted,  561. 
cysts  of,  597. 
development  of,  117. 
displacement  of,  560,  563. 
effects  of  removal,  586. 
gonococcous  infection  of,  574. 
hematoma  of,  618. 
hernia  of,  126,  564. 
hyperaemia  of,  567. 
hypertrophy  of,  594. 
individual  infections  of,  571. 
infections  of,  567. 
inflammation  of,  567. 
in  myomectomy,  407. 
malformations  of,  560. 
menstrual  function  of,  709. 
neoplasms,  malignant,  619. 
neoplasms  of,  597. 


Ovary,  papilloma  of,  608. 

pneumococcous  infection,  574> 

prolapse  of,  553. 

psammoma  of,  621. 

radical  operations  on,  584. 

rudimentary, 
etiology,  561. 
diagnosis,  561. 
frequency,  560. 

treatment  of  infections,  581. 

trophic  diseases  of,  592. 

tuberculosis  of,  575. 

unilateral  removal  of,  585. 
Ovulation,  710. 

dangers  of,  14. 

in  INIacacus  rhesus,  710. 

pathological  states,  13. 

relation  to  menstruation,  710. 

Semnopithccus,   710. 
Ovum,  impregnation  of,  650. 
Oxygen  in  anaesthesia,  93. 

Pacinian  corpuscle,  203. 

Pack,  dry,  8.3. 

Packer,  vaginal,  450. 

Paederasty,   821. 

Pain,  as  a  symptom  of,  adhesions,  631.. 

cirrhosis,  591. 

ectopic  pregnancy,  661. 

hematoma  of  ovary,  618. 

hemorrhage,  78. 

hydrosalpinx,  505. 

flbromyomata,  401. 

movable  kidney,  758. 

ovarian  neoplasms,  632. 

pyosalpinx,  .506,  509. 

renal  calculi,  778. 

renal  neoplasms,  786. 

salpingitis,  501,  535. 

torsion  of  tumour  pedicle,  628. 

tubal  tuberculosis,  526. 

tubercular  peritonitis,  694. 
Pain,   intermenstrual,   etiology,   734. 

pathology,  735. 

treatment,  735. 
Pain,  menstrual,  725. 
Pajot,  470. 

Palmer,  C.  D.,  313,  364,  680,  734. 
Palmer's  dilator,  364. 
Palpation,  abdominal,  40. 

of  Fallopian  tubes,  516. 

of  kidney,  40. 
Panhysterectomj',    abdominal,    415;  illus.,. 
p.  416. 

advantages,  419. 

angeiotribe  in,  418. 

electric  clamp  in,  419. 

hemostasis  in,  417. 

Reed's  operation,  417. 

results,  555. 

specimen,   illus.,   pp.  418,   420. 

technique,  415. 
Panhystercciomy,    abdomino-vaginal,    453,. 

indications,  453. 
Paoli,  171,  175. 


INDEX 


889 


Papillae  in  condylomata,  214. 
Papillary  cyst,  607. 
development,  607. 
Papilloma,  of,  bladder,  798. 
Fallopian  tubes,  478. 
histology,  479. 
origin,  478. 
rupture  of,  480. 
symptoms  of,  480. 
treatment,  480. 
ovary,  608. 
histogensiS,  609. 
histology,  608. 
rectum,  causes,  843. 
treatment,  843. 
Paquelin,  349. 
Paquelin's  cautery,  80. 
Paralysis  of  uterine  wall,  325. 
Parasites  of  external  genitalia,  205. 
Phtheirius  inguinalis,  206. 
Trichophyton  tonsurans,  205. 
Par§,  461. 

Park,  Roswell,  437,  442. 
Parker,  Rushton,  392,  593,  707. 
Parks,  736. 
Paroophoron,  671. 

cysts  of,  671. 
Parovarium,   anatomy,   670. 
embryology,  670. 
neoplasms  of,  669. 
Parry,  649. 
Parsons,  A.,  706. 
Parturition,   injuries  from,  136. 
Parvin,  649. 
Passet,  55. 
Paste,  Lassar's  200. 
Pasteur,  50,  61,  531. 
Patches,  mucous,  187. 

treatment,  188. 
Pathologic  laws,  deviations  from,  12. 
Pathologic  states,  due  to  gestation,  14. 
menstruation,  12. 
ovulation,  13. 
Pathology  of,  atrophy  of  ovaries,  593. 
vulva,  209. 
displacements  of,  Fallopian  tubes,  47.3. 
ovaries,  560. 
rectum,  818. 
uterus,  286. 
vagina,  2.38. 
female  generative  organs,  12. 
Infections  of,  bladder,  792. 
broad  ligament,  688. 
external  genitalia,  163. 
Fallopian  tubes,  489. 
ovary,  571. 
uterus,  359. 
inversion  of  uteru.s,  327. 
laceration  of  cervix,  334. 
prolapsus  uteri,  319. 
pruritus  vu\y>f%  203. 
puerperal  fi-vcr,  .'!76. 
Bliock,  72. 
Patient,  preparation  for  operation,  412. 
for  Caesarean  section,  403. 


Patient,  sterilization  of,  66. 
Paul,  of  iEgina,  1. 
Paul,  70 

Pawlick,  635,  746,  767,  800. 
Pean,  81,  380,  385,  386,  544,  557,  638. 
Pean's  forceps,  422. 
Peaslee,  144,  269,  312,  638. 
Pedicle,     extra-peritoneal     treatment     of, 
414. 

ligation  of,  in  ovariotomy,  642. 

torsion  of,  629. 

treatment  in  mj'omectomy,  407. 
Pediculi  pubis,  206. 

treatment,  206. 
Pelvic  diaphragm,  284. 
Pelvic    diseases    and    nervous    affections^ 

856. 
Pelvic  floor,  anatomy  of,  250. 

deep  injuries,  271. 

function  of,  250. 

injuries,  253. 

muscles  of,  250. 

restoration  of,  258. 
Pelvic  massage,  25. 

varicocele,  684. 
Pelvis,  measurement  of,  464. 

suppuration  in,  165,  689. 
Penis,  imperforate,  125. 
Peraire,   391. 

Percussion  of  abdomen,  40. 
Perimetritis,  575. 
Perineorrhaphy,  258. 

Emmet's  operation,  260. 

immediate  operation,  258. 

instruments  for,  259. 

posture  for,  260. 

Reed's  operation,  263. 

Tait's  operation,  267. 
Perineo-scrotal  hypospadias,   125. 
Perineum,  definition,  231. 

function  of,  2.54. 

injuries  of,  162. 

laceration  of,  253. 

malformations  of,  124. 

preservation  of,  256. 

syphilitic  ulcers  of,  189. 
Perioophoritis,  367. 
Periproctitis,  causes,  826. 

treatment,   826. 
Peritoneum,  incision  of,  108. 

infection  of,  115,  688. 

toilet  of,  in  salpingectomy,  553. 
in  ovariotomy,  643. 

tuberculosis  of,  692. 
Peritonitis,  116. 

puerperal,  380. 
Pessary,  240. 

danger  of,  362. 

gauze,  305. 

in  Caesaroan  section,  467. 

in    treatment    of    uterine    displacement^ 
311,  .322,  393. 

medicinal,  144. 
I'estalozzi,  7. 
I'eters,  427,  657,  658. 


890 


A  TEXT-BOOK  OF   GYNECOLOGY 


Petit.  Paul,  600,  685,  721. 

Pfahler,  70. 

Pfannenstiel,   603,   606,   607,  609,   610,   611, 

620,  622. 
Pfeiffer,  201. 
Pflster,  587,  588,  589. 
Pfliiger,  609,  710. 
Pfliiger's  loops,  671. 
Phj'sical  examination,  31. 
Physique  of  women,  5. 

of  Indian  women,  6. 
Pichevin,  366. 
Pick,  373,  434,  436,  625. 
Pieque,  458. 
Pilliet,  600. 
Pincus,  367. 
Pirmer,  521. 
Placenta,  location  of,  466. 

location  of,  in  ectopic  pregnancy,  666. 

removal  of,  in  Csesarean  section,  408. 
Placontoma     malignum,     see     Syncytioma 

maiignum. 
Phleboliths  of  broad  ligament,  682. 
Plethora,     as    a    cause    of    menorrhagia, 

714. 
Pliny,  460. 
Plumb,  702. 

Pneumococcous     infection     of     Fallopian 
tubes,  etiology,  529. 

course  of  infection,  529. 

symptoms,   529. 
Pneumococcous   infection  of  ovaries,   574. 

pus  in,  575. 

treatment,  582. 
Poise  of  uterus,  15. 
Poisoning,  septic,  73. 
Polk,  21,  294,  369. 
Polypus,  rectal,  841. 

uterine,  424. 
extirpation  of,  424. 
hemorrhage  from,  425. 

vaginal,  226. 

vulvar,    219. 
Pomorski,  626. 
Pompilius,  460. 
Porro,  335. 
Porro's  operation,  465. 

indications,  471. 

technique,  472. 
Portio  vaginalis,  carcinoma  of,  438. 
Position,  normal,  of  uterus,  285. 
Posner,  791. 

Post-operative  antisepsis,  68. 
Posture,  dorsal,  33;  illus.,   p.  33. 

for     examination     of     uterine    displace- 
ments, 290;  illus.,  p.  290. 

for    perineorrhaphy,    260;  illus.,    p.    262. 

knee-chest,  34;  illus.,  p.  34. 

Sims's,  42;  illus.,   p.  43. 

standing,  35;  illus.,  p.  35. 

Trendelenburg,  454;  illus.,  p.  454. 
Potter,  7,  32,  647. 
Poupinel,  225. 
Powder,  dusting,  196. 
Powell,  826. 


Pozzi,  131,  171,  218,  240,  282,  358,  368,  390, 

391,  440,  521,  635,  647,   679. 
Precocity  in  development  of  vulva,   men- 
strual, 701. 
Pregnancy,    after,    conservative   operation 
on  ovary,  583. 
myomectomy,  408. 
rupture  of  uterus,  334. 

complicating  carcinoma,  443. 
ovarian  tumours,   627,  634. 

echinococcous  infection  in,  394. 

gonorrhoea  in,  375. 

ovariotomy  in,  647. 

rape  in,  158. 

tuberculosis  in,  389. 
Pregnancj',  ectopic,  15. 

abortion  in,   655. 

action  of  syncytium,  655. 

ampullar,  652. 

capsularis  in,  658. 

changes  in  muscularis,  659. 

classification,  652. 

course,  054. 

decidua  in^  656. 

definition,  650. 

diagnosis,  662. 

etiolog}',  650. 

histology,  656. 

history,  649. 

interstitial,   652. 

intervillous  space  in,  659. 

instruments  for,  103. 

isthmic  tubal,  652. 

menstrual  changes,  661. 

mortality,  665. 

operation,  665. 

pain  in,  661. 

placental  site,  666. 

rupture  of,  654,  661. 

symptoms,  660. 

termination,  654. 

treatment,  664. 

treatment  of  sac,  666. 

tubo-abdominal,  653. 

tubo-ovarian,  653. 

tubo-uterine,   652. 

vaginal  examination  of,  662. 
Pregnancy,  ovarian,  illus.,  pp.  653,  654. 
Prepuce,  adhesions  of,  120,  211. 

hypertrophy  of,  220. 

operations  on,  218. 
Pressure,  as  a  hemostatic,  80. 
Preuschen,  224. 
Prevention    of    conception    as    cause    of 

genital  disorders.  10. 
Price,  Joseph,  403,  552,  653,  703. 
Priestley,   734. 
Prochownick,  671. 
Procidentia  after  colostomy,  847. 
Proctitis,  820. 
Proctoscope,  812. 

use  of,  815. 
Proctoscopy,  instrumental,   chair  for,  811. 
instruments,  812. 
postures  for,  813. 


INDEX 


891 


Proctoscopy,       instrumental,       technique, 
813. 
noninstrumental,   technique,   808. 
Proctotomy,  internal,  840. 
external,  840. 
posterior,  846. 
Prolapse  of,  ovary,  563. 
diagnosis,  564. 
symptoms,  564. 
treatment,  564. 
rectum,  820. 
causes,  818. 
colotomy  for,  820. 
symptoms,  819. 
treatment,  819. 
urethra, 
causes,  802. 
treatment,  802. 
uterus,  161,  275,  317;  illus.,  p.  317. 
-Congenital,  279. 
diagnosis,  321. 
hygienic  treatment,  322. 
infection  in,  362. 
mechanical  treatment,  318. 
mechanism  of,  318. 
medicinal  treatment,  321. 
pathologic  changes,  319. 
pessary  for,  322. 
symptoms,  321. 
tampon  for,  322. 
vagina,  237. 
etiology,  238. 
Prolegomena,  1. 

Proliferating  cysts,   classilication,  602. 
contents,  603. 
histology,   603. 
Prophylaxis,  258. 
Prostitutes,  9. 
chancroid  in,  182. 
gonorrrhoea  in,  166. 
herpes  in,  281. 
Protonuelein,  21. 
Pruritus  ani,  825. 
Pruritus  vulvae,  203. 
etiology,  204. 
in  kraurosis,  209. 
pathology,  203. 
treatment,  204. 
Pryor,  295,  304,  305,  555,  558,  559. 
Pryor's  operation   for  retro-displacements 

of  uterus,  305. 
Psammoma  of  ovary,  621. 
Pseudo-hermaphroditism,  213. 
feminine,  126. 
masculine,  125. 
Pseudo-mucin,  606. 

test  for,  606. 
Pseudo-mucinous  cyst  of  ovary,   contents, 
605. 
frequency,  603. 
histology,  606. 
section,   Illus.,   p.  605. 
symptoms,  604. 
Psychoses,  as  a  result  of  oophoritis,  580. 
Pubertas  praicox,  124. 


Pubescent  uterus,  symptoms,  277. 

treatment,  277. 
Pubo-coccygeus  muscle,  250. 
I'ubo-rectalis  muscle,  252. 
Pudendal  hematocele,  135. 

infection  of,  138. 

symptoms,  137. 

treatment,  138. 
Pudendum,  definition,  117. 

hypertrophic   and   hyperplastic    diseases 
of,  213. 

infections  of,  163. 

neoplasms,   benign,   221. 
malignant,  227. 
Puerperal  fever,  52. 

infection,  10,  18,  178. 

tuberculosis,   389 
Puncture,  as  means  of  diagnosis,  635. 
Pus,  evacuation  of,  548. 

chancroidal,  183. 

gas-bearing,  180. 

gonorrhoeal,  515. 

post-operative,  68. 
Pustules,  papulo-,  199. 
Pyaemia,  57. 

symptoms,  58. 
Pyelitis,  768. 

tuberculous,  773. 
Pyosalpinx,  bacteria  of,  485. 

contents  of,  500. 

cultures  from,  500. 

diagnosis,  508,  510. 

etiology,  499. 

pain  from,  506. 

pulse  in,  506. 

relation  to  hydrosalpinx,  495. 

section  from,  501. 

symptoms,  506. 

temperature,  506. 

Quadrants  of  abdomen,  41. 
Quain,  670. 
Quervain,  681. 
Quincke,  195. 

Rabenan,  383. 

Raciborsky,  710,  738. 

Radicalism  in  gynecology,  4. 

Ramsay,  786. 

Ranieri,  130. 

Rape,   general  indications,   159. 

hemorrhage  from,  158. 

infection  from,  158. 

injuries  from,  158. 

objective  evidences,  156. 

pregnancy,  158. 
Ravogli,    18,    184,    187,    188,    189,    191,    192, 
193,   195,   196,   197,   198,   199,   200,  202, 
204,  206,  215,  216. 
Raynaud,  712. 
Raynaud's  disease,  196. 
Recamier,  1,  2,  368,  447. 
Recklinghausen,  von,  397,  401. 
Rectal  infusion,  77. 
Rectocelc,  238,  240,  257. 


892 


A  TEXT-BOOK  OF   GYNECOLOGY 


Rectocele,   anterior,   817. 

operations  for,  269,  241. 

pathology,  818. 

posterior,   817. 

treatment,  818. 
Recto-vaginal  fistula,   illus.,   p.   151. 

etiology,  152. 

operation,  153. 

suture  for,  153. 
Rectum,  adenoma  of,  841. 

adhesions  of,  823. 

anatomy  of,  806. 

angeioma  of,  843. 

carcinoma  of,  844. 

chancre  of,  828. 

chancroid,  .828. 

condylomata  of,  828. 

curettage  of,  846. 

dermoid  cysts  of,  844. 

displacements  of,  817. 

divulsion  of,  840,  846. 

enchondroma  of,  844. 

etiology  of  diseases,  820. 

examination  by,  39. 

examination  of,  808. 

excision  of,  847. 

fibroma  of,  843. 

fistula  of,  831,  835. 

foreign  bodies  in,  821. 

gonorrhoea  of,  826. 

gummata,  829. 

infections  of,  824. 

in  pelvic  inflammations,  822. 

lipoma  of,  842. 

malformations,  806. 

malignant  growths  of,  844. 

myoma  of,   844. 

neuralgia  of,  820. 

papilloma  of,  843. 

prolapse  of,  120,  818. 

relation   of   diseases   to    intrapelvic   dis- 
ease, 821. 

results  of  pressure  on,  822. 

retention  cysts  of,  844. 

sarcoma  of,  844. 

spraying  of,  834. 

stricture  of,  831,  8.37. 

syphilis  of,  828. 

teratoma  of,  844. 

tuberculosis  of,  830. 

ulceration  of,  820,  831,  833. 

valves  of,  810. 
Reduction  of  inverted  uterus,  328. 
Reed,  49,  57,  68,  70,  74,  98,  146,  209,  210, 
211,  231,  270,  282,   300,   310,   315,   316, 
325,   332,   339,   365,  400,   403,   410,   433, 
435,  443,  458,   542,   544,   552,   555,   578, 
582,  583,  588,  628,  805,  818. 
Reed's  treatment  of  endometritis,  365. 

operation  for  vesico-uterine  fistula,   344. 
vesico-vaginal  fistula,  146. 

operation  of  panhysterectomy,  417. 

suture     for     incomplete     laceration     of 
perineum.   263. 
Regions  of  abdomen,  41;  illus.,  p.  41. 


Rein,  703,  735. 

Reinecke,  716. 

Reis,   Bmil,  454,  458. 

Remy,  318. 

Repositor,   uterine,  291,  328. 

Respiration  in  puerperal  fever,  381. 

use  of  chloroform,  95. 
Rest,   as  a  general  remedy,  20. 
Restoration  of  pelvic  floor,  258. 

levator-ani  muscle,  71. 

posture  for,  260. 
Retention  of  cervical  fluid,  282. 

menstrual  fluid,  282,  783. 
Retro-deviations  of  uterus,  diagnosis,  289. 

symptoms,  289. 

treatment,   290. 
Reuss,  681. 
Reymond,  483,  492,  513,  515,  517,  518,  528, 

529,  530,  574,  580. 
Reynaud,  176. 
Rhabdomyomata,    783. 
Rhabdomyosarcomata,  783. 
Rhagades,  187. 
Rhazas,  328. 
Rheinstein,  525. 
Ricard,  392,  458. 
Richardson,   629. 
Richelot,  556,  559. 
Ricketts,  Edwin,  678. 
Ricketts,  B.  M.,  853. 

Ricketts's  operation  for  hemorrhoids,  853. 
Rieck,  171,  173. 
Ring  of  Bandl,  332. 
Rishmiller,  636. 
Robb,  229,  575. 
Robin,  600. 

Robinson,  346,  711,  719. 
Robson,  ^layo,  154,  155. 
Robson's  operation  for  fsecal  fistula,  153. 
Rockel,  389. 
Rogivue,  437. 
Rohrer,  201. 
Rokitansky,    325,    385,    435,    480,    495,    525, 

575,  599. 
Rollin,  COO. 
Room,  operating,  64. 
Rosenbach,  57,  180. 
Rosenmiiller,  670. 
Rosenwasser,  372,  678. 
Ross,  J.  P.  W.,  45,  135,  142,  150,  403,  414, 

415. 
Rosthorn,  514,  601. 
Rothrock,  245,  246,  624. 
Round  ligament,  hydrocele  of,  677. 

malformations  of,  298. 

opei-ations  for  shortening  of,  294. 

Reed's  forceps  for,  300. 
Rousan,  683. 
Roush,  801. 
Rousset,  461,  464. 
Roux,  Thomas,  368. 
Rovsing,  778,  791. 
Rubber  gloves,  70,  295. 
Rubber,  Turck's  protective,  102. 
Rudimentary  uterus,  symptoms,  276. 


INDEX 


893 


Rudimentary  uterus,   treatment,  276. 
Rueff,   137. 
Ruggi,  294. 
Ruppolt,  474. 

Rupture  of  cysts  of  broad  ligament,  675. 
ectopic  pregnancy,  654,  661,  662,  663. 
hematocele,   137. 
ovarian  cyst,  631. 
perineum,  255. 
pyosalpinx,  507. 
tubal  papillomata,  480. 
uterus,  231. 
diagnosis,  332. 
etiology,  331. 
hsemorrhage  from,  335. 
mechanism,   331. 
pregnancy,   334. 
symptoms,   332. 
treatment,  333. 
vagina,  139. 
Rut,  menstrual,  700. 

Sactosalpinx  hemorrhagica,    499. 

purulenta,  499. 
Sahli,  25. 

Saline  waters,  321. 
Salochin,  374. 
Salpingectomy,  549. 

drainage  after,  553. 

enucleation  of  tumour  mass,  555. 

history,  549. 

indications,  551. 

objections  to,  550. 

Tait's  operation,  551. 

technique,  552. 

toilet  of  peritoneum,  553. 

treatment  of  pedicle,  552. 
Salpingitis,  acute,  histology,  489. 
secretion  in,  489. 

section  (infiltration),   illus.,  p.   491. 
section  (replacement  of  mucosa),  illus. 
492. 

catarrhal,  489. 

chronic,  adhesions,  493. 
as  cause  of  peritonitis,  493. 
bacteria  of,  484. 
histology  of,  491. 
Salpingitis,  illus.,  p.  494. 

complications  of  diagnosis,  503. 

compression  of  bladder,  507. 

conservative  operations  for,  546. 

constipation  in,  507. 

diagnosis,   501. 

distention  of  tube,  502. 

Doyen's  operation,  556. 

drainage  in,  540. 

dysmenorrhoea  in,  502. 

electricity  In,  539. 

evacuation  of  pus,  548. 

extension  of,  501. 

extravasation  of  lilood  in,  492. 

folllciil:irIs,  49:',. 

Koiiorrhf/'al,  507. 
diagnosis,  510. 
8ymr)torns,  507. 


Salpingitis,   hemorrhagic,  493. 
mechanical  symptoms, 
menstruation  in,  502. 
morbid  histology,  489. 
pain  from,  .501,  502. 

palpation  as  a  means  of  diagnosis,   503. 
panhysterectomy  for,  555. 
peritoneal  complications,  501. 
pseudo-foUicularls,  492. 
purulent,   494. 
radical  treatment,  549. 
secretion  in,  493. 
separation  of  adhesions,  547. 
sterility  from,  502. 
streptococcous,  507. 
symptoms,  507. 
diagnosis,  510. 
symptoms,  501. 
tuberculous,  511,  .521. 
Salpingo-oophorectomy,  551. 
Salt  solution,  74. 
infusion  of,  76. 
Salve,   resorcin,   194. 

Sanger,    70,    167,    245,    246,    247,    289,    294, 
427,  463,  470,  476,   478,   479,   638,  670, 
676,  677,  678,  679,  689. 
Sanger's  closure  in  Csesarean  section,  470. 
Saprsemia,  57. 

Saprophytic  infection  of  Fallopian  tubes, 
530. 
uterus,  377. 
pathology,  378. 
Sarcoma  deciduo-chorio-cellulare,  see  Syn- 

cytioma  malignum. 
Sarcoma  of  broad  ligament,  course,  686. 
treatment,  686. 
Fallopian  tubes,  482. 
histology,   482. 
treatment,  482. 
kidnej^  781. 
histology,  782. 
origin,  781. 
meatus  urinarius,  200. 
ovaiy,  frequency,  622. 
histology,  623. 
sections,  illus.,  624. 
symptoms,  623. 
urethra,  801. 
uterus,  432. 
etiology,  4.36. 
consistency,  4,32,  435. 
frequency,  432. 
hemorrhage  in,  434. 
histology,  433. 
injection  of,  436. 
inversion  in,  433. 
origin,  435. 

papilliferous  type,  433. 
recurrence  of,  437. 
secondary  degeneration,  434. 
treatment,  436. 
vagina,  232. 
adults,  2.32. 
children,  231. 
etiology,  232. 


894 


A  TEXT-BOOK  OF  GYNECOLOGY 


Sarcoma  of  vagina,   histology,  233. 

vulva,  229. 
Sasonoff,  137. 
Satti,  697. 
Sauter,  447. 

Savages,  menstruation  in,  699. 
Savor,  769. 

Saw,  spoon,  421;  illus.,  p.  422. 
Sawlzky,  55. 
Scanzoni,  674,  678,  739. 
Scar,  abdominal,  105. 
Schaeffer,  131. 
Schatz,  69,  272,  674. 
Schauta,  348,  349,  391,  513,  528,  530,   579, 

580,  665. 
Schedule  for  determination  of  rape,  160. 
Schenck,  171,  681. 
Schetelig,  678. 
Scheurlen,  441. 
Schick,  367. 
Schiller,  373. 
Sehleich,  97. 

Schleich's  anaesthetic  mixture,  97. 
Schlenker,  615. 
Schlesinger,  549. 
Schmidt,  678,  769. 
Schmorl,  389,  562. 
Schniir,  763. 
Schonheimer,   733. 
Schottlander,  575,  576. 
Schramm,  521. 
Schroeder,  171,  175,  366,  435,  440,  525,  638, 

671,  678,  692,  730. 
Schuckbardt,  520. 
Schiicking,  76. 
Schiill,  389. 

Schultze,  362,  363,  372. 
Schiitt,  385. 
Schwartz,  227,  392. 
Searcher,  ureteral,  747. 
Section,  abdominal,  99. 

Csesarean,   460. 
Secretion  of  cervix,  353. 
retention  of,  282. 
operation  for  retention,  279. 

endometrium,  350. 

vagina,  1G4,  351. 

vulvo-vaginal  gland,  243. 
Segond,  529,  554,  682. 
Segregator,  urine,  747. 
Seleneff,  374. 
Semen,  stains  from,  158. 
Semnopithecus,   menstruation  of,  699. 

ovulation  of,  710. 
Senator,  780. 

Senn,  67,  68,  678,  679,  681,  843. 
Sepsis,  bacteria  of,  50. 

definition  of,  50. 

general,  57. 
symptoms,  58. 
treatment,  58. 

local,  56. 
symptoms,  56,  73. 

preventive  treatment,  66. 
Septate  uterus,  277. 


Septate  uterus,  menstruation  from,  277. 

pregnancy  in,  277. 

symptoms,  277. 
Septicaemia,   see  Sepsis. 
Serous  cysts,  607. 

contents,  608. 

frequency,  607. 

histology,  608. 
Serpentine  suture.  111. 
Serum  therapy,  21,  44,  45. 

in  general  sepsis,  59. 
Sex,  differentiation  of,  117. 
Sexual  anaesthesia,  9. 

perversions,  9. 
Seydel,  549. 
Shock,   causes,  72. 

definition,  72. 

diagnosis,  73. 

pathology,  72. 

symptoms,  72. 

treatment,  74,  630. 
Silk  ligature,  86. 

Simon,  G.,  144,  230,  447,  541,  635. 
Simon-Hegar   operation   for   complete   lac- 
eration, 270. 
Simon's  speculum,  371. 
Simpson,  2. 

Simpson,  Sir  James,  91,  312,  950. 
Sims,  J.  Marion,  2,  42,  143,  145,   146,  154,. 
305,  312,   313,   314,  323,  326,   337,   368, 
420,  425,  445,  448,  4.52,  538,  726,  730. 
Sims's  operation  for  urinary  fistula,  144. 

posture,  33. 

speculum,  142. 
Sinclair,   352,  355,   356,   357,   361,  364,   484, 

487,  5.30. 
Sinus,  urogenital,  122. 
Sippel,  385,  .391,  453,  588,  692,  697. 
Sitz  bath,  204. 

Skene,  84,  85,  148,  244,  419,  448,  642,  681. 
Skene's  gland,  244. 

gonorrhoea  of,  244. 
Skin,  disinfection  of,  295. 

of  genitalia,  191. 
Skirving,  121. 
Slansky,  478. 
Smith,  Albert,  293. 
Smith,  Greig,  681. 
Smith,  Nathan,  638. 
Smith,  Tyler,  329. 
Sneguireff,  364. 
Social  evil,  as  cause  of  diseases  of  women,. 

10. 
Solowieff,  3.5.3. 
Solution,  Burow's,  196. 

Florence,  158,  159. 
Soranus,  1. 
Sound,  32. 

as  means  of  diagnosis,  4.5. 

dangers  of,  291. 

Ross's  intrauterine,  45. 

uterine,  345. 
Spaeth,  324,  385,  F87. 
Specialism  in  gynecology,  2. 
Speculum,  as  means  of  examination,  42.. 


INDEX 


895 


Speculum,  Gau's,  44;  lllus.,  p.  4.'5. 
infection  from,  362. 
Jones's,  370. 
Miller's,  44. 
Nott's,  44. 
Simon's,  371. 
Sims's,  32;  illus.,  p.  42. 
Sims-Emmet,  43. 
vesical,  746. 
Spermatozoa,  determination  of,  159. 
Speth,  481. 
Spliincter-ani-externus  muscle,  250. 

restoration  of,  269. 
Sphincter  vagina  muscle,  237. 
Spiegelberg,  137,  671,  674. 
Sponge  hoklei-,  450. 
Spores,  annihilation  of,  61. 
Spronius,  549. 
StafEordshire  knot,  552. 
Stains,  seminal,  158. 
Standing  posture,  35. 
Stanley,  24. 
Staphylococcous  epidermidis  albus,  51. 

infection,  196,  5.30. 

pyogenes  albus,  51,  196. 
aureus,  50,  53. 
citreus,  52. 
St.  Braunwas,  334. 
Steffeck,  610. 
Steihitz,  797. 
Steinmetz,  799. 
Steinschneider,  514. 
Stemann,  524. 
Stenosis,  as  cause  of  dysmenorrhoea,  726. 

electricity  in,  730. 

operation  for,  281. 

uterine,  280. 

vaginal,  129. 
Stephenson,  707. 
Stephenson's  wave,  707. 
Sterility,  502,  509. 

etiology,  141. 
Sterilization,  germicidal  agents  for,  63. 

heat  for,  61. 

mechanical  means,  61. 
Sterilization  of,  dressings,  66. 

hands,  69. 

instruments,  66. 

operating  room,  64. 

patients,  66. 

surgeon,  69. 

sutures  and  ligatures,  67. 

vagina,  313. 
Sterilizer,  steam,  of  Colonel  John  Fehren- 

batch,  61;  illus.,  p,  61. 
Sternberg,  51,  53,  61. 

Stethoscope,  as  means  of  examination,  47. 
Stf^venson,  24. 
Still.',  376. 
Stirton,  James,  699. 
Stockard,  .'!97. 
Stocfkllii,  .571. 
Ktollz,  463. 

Sloiiiach,   inenstruaf  Ion  from,  7.'i6. 
StomatoplaBcy,  IIIuh.,  p.  280. 


Stomatoplasty,  indications  for,  282. 

technique,  283. 
Storer,  471. 
Stratz,  401. 

Streptococcous  infection  of  external  geni- 
talia, 177. 
treatment,  178. 
Fallopian  tubes,  516. 
diagnosis,  516. 
fimbria,  517. 
mucosa  in,  517. 
palpation  of,  516. 
pathology,  517. 
pus  from,  517. 
symptoms,  516. 
ovaries,  569. 
course,  569. 
pathology,  571. 
treatment,  581. 
uterus,  376. 
diagnosis,  381. 
pathology,  376. 
symptoms,  380. 
treatment,  381. 
pudendum,  177. 
vagina,  177. 
Streptococcus   pyogenes,    52;  illus.,    p.    52. 

erysipelatos,  52. 
Streptothrix     actinomyces,     infection      of 

Fallopian  tubes,  531. 
Stricture,     of    rectum,     carcinoma    as     a 
cause,  838. 
etiology,  837. 
diagnosis,  839. 
dysenteric,  838. 
symptoms,  838. 
syphilitic,  838. 
traumatic,  838. 
treatment,  839. 
tuberculous,  838. 
ureter,  760. 
dilatation  of,  761. 
operation  for,  761. 
urethra,  802. 
etiology,  802. 
treatment,  802. 
Stroganoff,  163,  165,  353,  530. 
Struma     suprarenalis     lipomatodes     aber- 

rans,  785. 
Styptics,  79. 
Subcostal  incision,  106. 
Sultcutaneous  infusion,  76. 
Suggestion  as  a  therapeutic  agency,  23. 
Superinfection,   gonococcous,  375. 
Suppinger,  120. 
Suppuration,  55. 

pelvic. 
Suprapubic  incision,  106. 
Suprarenal  extract,  75. 
Sufjra vaginal  hysterectomy,  410. 
indications,  411. 
ills!  I'uriienis,  103. 
techni(|ue,  412. 
Surgeon,  pr('i)aralion  for  examination,  33. 
sterilization  of,  69. 


896 


A  TEXT-BOOK   OF  GYNECOLOGY 


Sutton,  Bland,  475,  478,  480,  489,  493,  495, 

497,  552,  558,  588,  589,  617. 
Suture,  buried  serpentine,  111. 
catgut,  67. 
crown, 
Emmet's,  262. 
Reed's,  263. 
en  masse,  112. 
figure-of-eigiit,  113. 
intercutaneous,  110. 
laminated,  109. 
removal  of,  340. 

after  urinary  fistula,  150. 
sterilization  of,  67. 
wire,   144. 
Syms,  Parker,  698. 
Syncope,  73. 

Syncytioma  malignum,  15,  231,  426. 
diagnosis,  428. 
etiology,  428. 
hemorrhage  in,  428. 
histology,  427. 
metastasis  in,  429. 
pain  in,  428. 
pathology  of,  427. 
results  of  operation,  429. 
source  of,  427. 
symptoms,   428. 
treatment,  429. 
Syncytium,  action  of,  655. 

in  ectopic  pregnancy,   660. 
Syphilis,  as  cause  of  pelvic  diseases,  11. 
bacteriology  of,  186. 
from  rape,  1.58. 
Syphilis  of  broad  ligament,  690. 
histology.  G90. 
diagnosis,  690. 
external  genitalia,  17,  189. 
uterus,  391. 
cauterization  in,  393. 
diagnosis,  393. 
primary,  392. 
secondary,  392. 
symptoms,  392. 
treatment,   393. 
rectum,  congenital,  828. 
stricture  from,  838. 
treatment,  829. 
Syringe,  Davidson's,  76. 
Szancer,   394. 

Table,  Bozeman's,  143. 
Tachycardia  at  menopause,  740. 
Tait,    Lawson,    2,    99,    126,    137,    144,    1.54, 
166,  210,   216,  266,  267,  269,   271,   272, 
306,   .328,   329,  345,   347,   350.   3.52,   353, 
357,  584,   586,   637,   638,   640,  641,   649, 
689,  709,  805. 
Tait's    operation    for    complete   laceration 
of  perineum,  267. 
removal  of  Fallopian  tubes,  551. 
Tampon,   chain,  292;  illus.,   p.   292. 
improper,  292;  illus.,  p.  292. 
lamb's  wool,  293;  illus.,  p.  29.3. 
method  of  inserting,  537. 


Tampon,   proper,   292. 
Tampon  for,  bleeding,  215. 

carcinoma  uteri,  445. 

diagnosis  of  endometritis,  363. 

eczema,  197. 

gonorrhoea  of  uterus,  875. 

inversion  of  uterus,  329. 

menorrhagia,  716. 

prolapsus  uteri,  322. 

pruritus  vulvae,  204. 

puerperal  fever,  382. 

salpingitis,  537. 

uterine  displacement,  291. 
Tarulli,  .589. 

Taylor,  George  H.,  24,  182. 
Temesvary,  624. 

Temperature,  in  puerperal  fever,  380. 
Tenacula,  371. 

Cullen's,  450. 
Tent,  laminaria,  356. 
Teratoma,  of  ovary,  614. 

of  rectum,  844. 
Testicle,  coexistence  of,  with  ovary,  562. 
Thayer,  514. 
Themison,  328. 

Therapeutics  of  gynecology,  20. 
Therapy,  serum,  21. 
Thlem,  C,  161. 
Thiriar,  310,  315. 

Thomas,  Gaillard,  293,  322,  329,  429,  447. 
Thomas's  serrated  spoon  saw,  421. 
Thomson,  279,  318,  754. 
Thorn,  389,  458. 
Thornton,  628,  638. 
Thrush,  179. 
Thumin,  81. 
Thyroid  gland,  extract  of,  21. 

as  a  styptic,  79. 

relation  to  uterus,  21. 
Til  laud,  388. 
Tilt,  738. 

Tongue  forceps,  95. 
Toxaemia,  57. 

Toxine,  treatment  with,  436. 
Trachelorrhaphy,  illus.,  p.  339. 

instruments  for,  338. 

sutures  for,  339. 

technique,  338. 
Transfusion  of  blood,  76. 
Transversus-perinsei  muscle,  250. 
Trekaki,  7.54. 
Trendelenburg,  304,  315. 

posture,    illus.,   p.   454. 
Treub,  .325,  327. 
Trichophyton  tonsurans,  205. 
Trifld  uterus,  275. 
Trocar,  illus.,  p.  640. 
Trommer,  606. 
Trophoblast,  657. 
Tsokana,  149. 
Tubercle,  genital,  117. 

double,  121. 
Tuberculosis,  bacillus  of,  55. 
Tuberculosis,  of  bladder,  792. 

broad  ligament,  691. 


INDEX 


897 


Tuberculosis,  of  cervix,  385. 
classilication,  385. 
diagnosis,  386. 
diffuse  form,  386. 
etiology,  385. 
miliary  form,  385. 
morbid  anatomy,  385. 
papillary  form,  386. 
resemblance  to  epithelioma,  387. 
symptoms,  386. 
treatment,  387. 
Fallopian  tubes,  519. 
acute,  524. 

adenomatous  tumour  formations  525. 
ascending  form,  520. 
chronic,  324. 
complications  of,  526. 
descending  form,  521. 
diagnosis,  526. 
distention  from,  522. 
frequency  of,  520. 
gonococcus  in,  525. 
hematogenous  infection,  521. 
menstruation  in,   526. 
method  of  infection,  520,  521. 
morbid  anatomy  of,  521. 
mucosa  in,  524. 
pain  in,  526. 
primary,  520. 
prognosis  of,  527. 
secondary,  520. 
spontaneous  cure,  525. 
symptoms,  525. 
treatment,  527. 
kidney,  772. 
abscesses  in,  773. 
changes  in  urine,  774. 
diagnosis,  774. 
frequency  of,  772. 
giant  cell,  illus.,  p.  77.3. 
hematuria  in,  774. 

involvement  of  ureter,   774. 

method  of  infection,  772. 

pain  in,  774. 
pathology,  77.3. 

symptoms,   774. 

treatment,  775. 
ovary,  575. 

diagnosis,  .577. 

frequency  of,  575. 

mode  of  infection,  576. 

morbid  anatomy,  576. 

symptoms,  577. 

treatment,  .578. 
peritoneum,  692. 

anatomy,   morbid,  692. 

caseous  variety,  693. 

diagnosis  of,  695. 

drainage  in,  697. 

<•!  iology,  (J92. 

fever  In,  694. 

fibroid  variety,  694. 

miliary  variety,  692. 

omental  tumour  In,  695. 

pain  from,  694. 
58 


ruberculosis,  of  peritoneum,  prognosis,  696. 

results  of  operation,  697. 

symptoms,  694. 

treatment,  696. 
rectum,  830. 

etiology,  830. 

fistula  from,  830. 

forms  of,  831. 

stricture  from,  831,  838. 

symptoms,  831. 

treatment,  832. 
urethra,  173. 
uterus,  357,  384. 

caseous  form,  390. 

cauterization  of,  391. 

course  of  infection,  388. 

curettage  for,  391. 

diagnosis  of,  390. 

discharge  in,  390. 

etiology,  388. 

fibroid  type,  390. 

glands  in,   391. 

hysterectomy  for,  391. 

miliary  form,  389. 

morbid  anatomy,  389. 

pathology,  389. 

pregnancy  in,  389. 

symptoms,   390. 

treatment,  391. 
vagina,  175. 

diagnosis,  177. 

etiology,  175. 

symptoms,  176. 

treatment,  177. 
vulva,  17,  165. 

diagnosis  of,  174. 

etiology  of,  171. 

morbid  anatomy,  172. 

symptoms,  174. 

treatment,  175. 

Tubes,   accessory,   749. 

drainage,  112,  114. 

through-and-through,  542. 
Fallopian,  see  Fallopian  tubes. 
Kobelt's,  671. 
supernumerary,  474. 
Tubo-ovarian  cyst,  69,  601. 
classification,   601. 
contents,  602. 
etiology,  601. 
histology,  602. 
origin,  418. 
Tuclierman,  778. 
TufHer,  81,  97,  528,  772. 
Tumours,  see  Neoplasms. 
Turck,  75,  102. 

Turck's  intragastric  resuscitator,  75. 
protective  rubber,  102. 

Ulcer,  anal,  8,32. 

destructive,  171. 

follicular,  ]8]. 

syphilitic,   189. 
ITlceration,   of  rectum,   820,   8.31. 

diagnosis  of,  834. 


898 


A  TEXT-BOOK  OF   GYNECOLOGY 


Ulcei'ation,  of  rectum,   symptoms,   833. 

treatment,  834. 
Ulcus  elevatum,  186. 

rodens  vulvEe,  171. 
Umbilical  incision,  106. 
Unicoinate  uterus,  276. 
Urachus,  anatomy  of,  803. 

cyst  of,  804. 
Ureters,  anomalies  of,  760. 

catheterization  of,  744. 

duplication  of,  760. 

injuries  of,  762. 

in  hysterectomy,  413. 

in  nephrectomy,  789. 

involvement  of,  in  carcinoma,  786. 

operations  on,  761. 

stricture  of,  760. 
Uretero-cystotomy,  761. 
Uretero-vaginal  fistula,  140. 

operations  for,  151. 
Urethra,  atresia  of,  150. 

carcinoma  of,  801. 

caruncle  of,  800. 

dilatation  of,  803. 

diseases  of,  800. 

diverticula  of,  801. 

foreign  bodies  in,  802. 

prolapse  of,  802. 

sarcoma  of,  801. 

stricture  of,  802. 

tuberculosis  of,  173. 
Urinary  apparatus,   examination  of,  744. 

flstulse,  139. 
Urines,  bacteria  of,  779. 

examination  of,  102. 

incontinence  of,  123,  134,  141. 

in  cystitis,  793. 

in  renal  infection,  771. 

residual,  239. 

segregation  of,  747. 

suppression  of,  779. 
Urogenital  sinus,  123. 

persistent,  122. 
Uronephrosis,   see  Nephrydrosis. 
Urticaria  of  Wilson,  195. 
Uterus,  absence  of,  276. 

accessorius,  275. 

adenoma  of,  429. 

adenomyoma  of,  397,  399. 

ante-deviations  of,  310. 

atrophy  of,  18. 

bacteria  of,  352. 

bicornate,  281. 

carcinoma  of,  437. 

chancre,  391. 

contraction  of,  468. 

curettage  of,  368. 

development  of,  274. 

displacements  of,  38,  284. 

double,  281. 

echinococcous,  cyst  of,  394. 
infection  of,  393. 

endothelioma  of,  434. 

examination  of,  47. 

fibromyomata  of,  396. 


Uterus,  fcetal,  277. 
foreign  bodies  in,   348. 
gonorrhoea  of,  354,  372. 
in  menorrhagia,  715. 
infantile,  277. 
infection  of,  16,  350,  372. 
injuries  of,  162,  331. 
inversion  of,  324. 
lymphatics  of,  350. 
malformations  of,  274,  279. 
malignant  neoplasms  of,  426. 
menstrual  function  of,  13,  708. 
movements  of,  284. 
myoma  of,  396. 
neoplasms  of,  396. 
normal  position  of,  284. 
poise  of,  15. 

polypoid  growths  of,  424. 
prolapse  of,  161,  275. 
pubescent,  277. 
repositor  for,  291,  328. 
rudimentary,  276. 
rupture  of,  331. 
saphrophytic  infection  of,  377. 
sarcoma  of,  432. 
septus,  277. 
stenosis  of,  280. 

streptococcous  infection  of,  376. 
suspensory  apparatus  of,  285. 
suture  for,  in  Csesarean  section,  468. 
syncytioma  malignum  of,  231,  428. 
syphilis  of,  391. 
trifld,  275. 

tuberculosis  of,  357,  384. 
unicornate,  276. 
vaginal  fixation  of,  303. 
wounds  of,  345. 

Vagina,  absence  of,  126. 
atresia  of,  163. 
Bilharzia  of,  180. 
carcinoma  of,  2.33. 
coitional,  128. 
cysts  of,  224. 
dermoid  cyst  of,  225. 
displacements  of,  237. 
douche  for,  32. 
endothelioma  of,  233. 
examination  by,  30,  165. 
extirpation  of,  455. 
fibroid  tumours  of,  225. 
infections  of,  16,  163. 
injuries  of,  139,  162. 
malformations  of,  126. 
neoplasms  of,   224. 

malignant,  231. 
Miillerian,  126. 
polyps  of,  226. 
prolapse  of,  237. 
sarcoma  of,  231. 
secretions  of,  164,  351. 
septate,  129. 
stenosis  of,  129. 
sterilization  of,  313. 
tuberculosis  of,  175. 


INDEX 


899 


Vagina,  virgin,  252. 
Vaginal  liysterectomy,  419. 
instruments,  103. 
myomotomy,  420. 
Vaginitis,  163. 

exfoliative,  167. 
Valve,  rectal,  810. 
Valvotome,  836. 
Van  Buren,  841. 
Vander  Veer,  403,  647. 
Van  de  Warker,  9. 
Van  Gieson,  480. 
Van  Heukelom,  427,  657. 
Van  Hook,  701,  762. 
Van  Scliaick,  372,  373. 
Varicocele,  pelvic,  682. 

diagnosis,  684. 

etiology,  683. 

history,  684. 

Reed's  operation  for,  68.5. 

symptoms,  684. 
Varicocele,  pudendal,   222. 
Varix,  aneurismal,  of  broad  ligament,  682. 
Vassmer,  385,  388,  389,  390. 
Veins  of  labia,  221. 
Veit,  171,  224,  226,  232,  318,  391,  397,  429, 

434,  470,  499,  521,  522,  525. 
Velits,  von,  626. 
Ventral  fixation,  306. 

incision,  100. 
Verneuil,  711,  849. 
Vertical  median  incision,  105. 
Vesicles,  herpes  progenitalis,  201. 
Vesico-umbilical  fistula,  804. 
Vesico-uterine  fistula,   140,  343. 

diagnosis,  343. 

Reed's  operation,  344. 
Vesico-vaginal  fistula,  1.39. 
Vestibular  band,  1.34. 
Vibriou  septique,  531. 
Vidal,  377,  379. 

Vineberg,  129,  276,  294,  304,  .383. 
Vinegar  as  a  styptic,  79. 
Violence,  injuries  from,  1.36. 
Virchow,  4.32,  435,  575,  609,  678. 
Virgin,  examination  of,  30. 

vagina,  252. 
Virus,  chancroidal.  183. 
Vitrac,  387. 
Volbrecht,  677. 
VoLsella,  Newman's.  .3.38. 
Vomiting  in  anaesthesia,  91. 
Von  PMselberg,  5],  57. 
Von  Guerard,  .■'.67. 
Von  Kohlden,  351,  352,  370. 
\'on  Laiig{'iib('ck,  447. 
^'oIl  Ilosthoni,  496,  574. 
ViilvM.  117. 

adhesions  of,  211. 

atresia  of,  119. 

atrophy  of,  207. 

blood  supply  of.  221. 

Ciircliioina  of,  227. 

chancre  of,  228. 

cloaca,   121. 


Vulva,  cysts  of,  223. 

eczema  ot,  196. 

elephantiasis  of,  216. 

enchondromata  of,  223. 

fibromata  of,  222. 

fibroma  molluscum  of,  223. 

fibrosarcoma  of,  229. 

folliculitis  of,  198. 

hematoma  of,  222. 

hemorrhage  from,  135. 

hypertrophy  of,  213. 

infantile,   120. 

injuries  of,  135,  157,  162. 

intertrigo  of,  191. 

lipomata  of,  223. 

malformations  of,  118. 

malignant  neoplasms  of,  227. 

melano-carcinoma  of,  231. 

melanosarcoma  of,  229. 

metastases  in,  231. 

molluscum  pendulum  of,  223. 

myomata  of,  222. 

myxoflbromata  of,  223. 

myxosarcoma  of,   229. 

neuromata  of,  223. 

noma  of,  169. 

cedema  of,  195. 

polypi  of,  219. 

precocious  development  of,  124. 

pruritus  of,  202. 

pseudo-hermaphroditism,  126. 

sarcoma  of,  229. 

tuberculosis  of,  171. 

varicose  tumours  of,  221. 
Vulvitis,  163. 
Vulvo-vaginal  anus,  122. 
Vulvo-vaginal  gland,  abscess  of,  245. 

anatomy,  243. 

carcinoma  of.  228,  249. 

cysts  of,  224,  247. 

function  of,  243. 

gonorrhoea  of,  170. 

infection  of,  243. 

inflammation  of,  144. 

Wagner,  787. 

Waldeyer,  602.  670.  689. 

Waldstein,  2.33. 

Wallace,  J.  R.,  737. 

Walther,  389,  391. 

Walton,   P.,  128,  129. 

Warburg,  536. 

Warnecke,  697. 

Warren,  70,  73.  74. 

Wart,   venereal,   see  Condylomata. 

Wave,  Stephenson's,  707. 

Weber,  248,  681. 

Webster,  126,  203,  205. 

Weigert,  694. 

Weight  of  brain,  7. 

Weir,  R.  P.,  70,  207. 

Welch,  52,  54,  180,  .358. 

Wells,   Spencer,  2,  627,  636,  638,  640,  642, 

676. 
Werder,  455. 


900 


A  TEXT-BOOK  OF  GYNECOLOGY 


Wernltz,  229. 

Werth,  56,  610,  670. 

Wertheim,  199,  294,  354,  356,  374,  375,  485, 

486,  513,  515,  529. 
Westermai'k,  485,  513. 
Westermeyer,  576. 
Westphalen,  13. 
Wetherill,  474. 
Whitacre,  228,  384,  385,  387,  491,  493,  576, 

577. 
White,  J.  W.,  216.  329,  781. 
Wliitehead,  392,  821. 
Whitehead's    operation    for    hemorrhoids, 

852. 
Wiart,  Pierre,  477. 
Wiclilein,  180. 
Widal,  52,  376. 
Wilhelm,  671. 

Wilson's  ointment,  193,  200. 
Williams,     386,     389,     473,     474,     475.     480, 

520,  521,   524,   525,   562,   610,   617,   692, 

627. 
Williams,  J.  Whitridge,  164,  105,  293. 

427,  615. 
Williams,  Roger,  427,  429,  433,  436. 
Wilms,  14,  613. 
Wiucke,  F.  von,  274. 


Winckel,   137,   229,  289,   474,   525,   561,   676, 

678,  679,  681,  682. 
Wing,  329. 

Winter,  164,  353,  360,  437,  484,  598. 
Withrow,  653,  720,  736. 
Witte,  484,  513,  528,  530,  531,  574,  575. 
Witzel,  801. 
Wladimiroff,  702. 
Wolf,  249,  805. 
Wolff,  525,  575,  577. 
Wolffian  body,  117. 

ducts.  126,  671. 
Wounds  of  uterus,  345. 
Wumsehein,  769. 
Wyder,  351. 
Wylie,  294,  299,  679. 
Wyssakovitscli,  60. 

Zahn,  389. 

Zeman,  531,  575. 

Zetter,  627. 

Ziegler,  597,  621. 

Zinke,  675,  678,  679,  680,  682,  683,  684,  685, 

686,  687. 
Zuckerkandl,  689. 
Zweifel,   180,   387,   470,   495,   513,   529,   530, 

550,  574. 


THE    END 


A  TEXT-BOOK  ON  SUROERY: 

GENERAL,    OPERATIVE,   AND   MECHANICAL. 
By  JOHN   A.    WYETII,  M.  D., 

Professor  of  Surgery  in  the  New  York  Polyclinic  ;    Surgeon  to  Mount  Sinai  Hospital,  etc. 
TRIRB  EDITION,   REVISED  AND  ENLABGED. 

997  pages,   with  938  Illustrations. 

Buckram,  uncut  edges,  $7.00  ;  sheep,  $8.00  ;  half  morocco,  $8.50. 
SOLD   ONLY   BY   SUBSCRIPTION. 


From  Autliofs  Preface. 

The  original  edition  of  this  work  was  published  in  1886.  It  was  revised  and 
enlarged  in  a  second  edition  in  1890.  "Within  the  period  of  seven  years  to  this 
date  (November,  1897)  so  many  important  advances  have  been  made  in  surgical  sci- 
ence and  the  operative  technique  that  the  author  has  found  it  necessary  again  to 
revise  and  practically  rewrite  this  volume.  To  add  all  that  was  new  and  acceptable 
to  that  which  experience  had  already  demonstrated  to  be  useful  has  of  necessity 
increased  the  number  of  pages  and  size  of  the  book.  By  careful  elimination  of 
matter  which  could  with  least  disadvantage  be  left  out,  this  volume,  however,  only 
exceeds  the  former  by  one  hundred  and  twelve  pages. 

It  has  been  the  author's  aim  to  retain  those  features  of  the  original  work  which 
made  it  available  to  the  busy  practitioner  for  quick  and  ready  reference,  and  to  add 
to  this  edition  some  elementary  pages  which  may  commend  it  to  teachers  for  their 
undergraduate  pupils.  With  this  end  in  view  the  matter  has  in  great  part  been 
rearranged. 

The  introductory  section  is  devoted  to  surgical  pathology,  subdivided  into  six 
chapters.  These  chapters  treat  of  inflammation  and  the  process  of  repair  in  the 
various  tissues  of  the  body,  and  the  differences  in  repair  in  a  tissue  affected  with 
simple  or  non-infective  and  infective  (or  suppurative)  inflammation.  Specific  and 
non-specific  urethritis,  erysipelas,  actinomycosis,  glanders,  tetanus,  malignant 
oedema,  hydrophobia,  tuberculosis,  syphilis,  leprosy,  diphtheria,  and  typhoid  infec- 
tion are  also  embraced  in  this  portion  of  the  work. 

Chapters  VII  and  VIII  are  devoted  to  surgical  dressings,  sterilization,  asepsis 
and  antisepsis,  and  anfesthesia. 

In  Chapters  IX  and  X  are  given  haemorrhage,  wounds,  burns,  skin  grafting, 
frostbite,  furuncle,  carbuncle,  ulcers,  and  gangrene.  Bandaging  is  given  in  Chap- 
ter XI.  and  Chapter  XII  is  devoted  entirely  to  amputations. 

Chapters  XIII,  XIV,  and  XV  deal  with  the  lymphatic  vessels  and  glands,  veins, 
arteries,  aneurism,  and  ligation  of  the  vessels. 

In  Chapters  XVI  and  XVII  are  given  the  lesions  of  the  bones  and  joints,  and 
the  various  operative  measures  for  their  correction. 

The  chapters  from  XVIII  to  XXIX  inclusive  are  devoted  to  regional  surgery, 
and  in  that  portion  of  this  section  in  which  the  abdomen  is  considered  many  im- 
portant changes  have  been  made  and  much  new  matter  added.  Chapter  XXX  takes 
up  deformities  and  their  correction,  while  the  final  chapter  (XXXI)  is  devoted  to 
the  suVjject  of  tumors. 

D.  APFLETON   AND   COMPANY,  NEW  YORK. 


A  TEXT-BOOK  OF 
OEINTEKAL    SUKOEKY. 

By   dr.   HERMANN   TILLMANNS, 

Pkofessok  m  the  University  or  Leepsic. 

VOLUME  I. 

The  Principles  of  Surgery  and  Surgical  Tathology.  General  Rules 
governing  Operations  and  the  Ajjplication  of  Dressings.  Translated  from 
the  third  Gerraan  edition  by  John  Rogers,  M.  D,,  and  Benjamin  T.  Tilton 
M.  D,     With  441  Illustrations. 

VOLUME   U. 
Regional  Surgery.      Translated  from  the  fourth  German  edition  by  Benjamin 
T.  Tilton,  M.  D.,  New  York.     With  417  Illustrations.     Edited  by  Lewis  A. 
Stimson,  M.  D.,  Professor  of  Surgery  in  the  New  York  University. 

VOLUME  IIL 
Regional  Surgery.     Translated  from  the  foui-th  German  edition  by  Benjamin 
T.  Tilton,  M.  D.,  New  York.     With  530  Illustrations.     Edited  by  Lewis  A. 
Stimson,  M.  D.,  Professor  of  Surgery  in  the  New  York  University. 


Cloth,  S5.00;   sheep,  S6.00  per  volume. 
SOLD    ONLY  BY  SUBSCRIPTION. 


Dr.  Hermann  Tillmanns,  I'rof'cssor  of  Surtjery  in  the  University  of  Leipsic,  possesses  as 
a  teacher  those  rare  qualities  which  enable  him  to  instruct  t.'ie  student,  step  by  step,  begiuniutr 
by  the  laying  of  a  tirm,  broad  foundation,  upon  which  is  Imilt  the  solid  surgical  structure.  It 
was  on  account  of  these  exceptional  qualities  of  the  author  that  his  work  was  selected  as  the 
best  for  the  use  of  students,  and  at  the  same  time  well  adapted  to  the  needs  of  the  practitioner. 

Surgery,  as  presented  in  the  present  volumes,  is  a  translation  of  his  works  on  General 
Surgery  and  Surgical  Pathology,  and  on  Regional  Surgery.  Of  the  latter  there  are 
two  volumes,  tUe  second  of  which  will  soon  be  on  press. 

Volume  I,  General  Surgery  and  Surgical  Pathology,  is  largely  devoted  to  the  expo- 
sition of  the  essential  principles  which  underlie  a  solid  surgical  structure.  This  applies  not 
only  to  general  surgical  operations,  but  also  to  all  surffical  conditions.  The  work  covers  the 
entire  field  of  general  surgery  and  of  surgical  diseases,  deahng  not  so  much  with  special 
operations  as  with  the  conditions  which  should  govern  them— general  directions  for  their 
performance,  after-treatment,  and  the  etiology,  pathology,  ancV  treatment  of  the  various 
surgical  diseases. 

Volume  II,  Regional  Surgery,  is  devoted  to  the  surgery  of  the  head,  neck,  thorax,  and 
spine  and  spinal  cord  ;  including  in  Xhe,  first  division  injunes  and  diseases  of  the  scalp,  of  the 
cranial  bones,  of  the  brain  and  its  adnexa,  of  the  face,  of  the  nose  and  nasal  fossas,  of  the 
jaws,  of  the  mouth,  fauces,  and  phai-ynx,  of  the  ear,  and  of  the  salivary  glands.  The  second 
divisio7i  includes  injuries  and  surgical  diseases  of  the  neck,  of  the  larynx  and  trachea,  and 
of  the  oesophagus.  The  third  division  covers  injuries  and  diseases  of  the  thorax  and  of  tlie 
heart;  and  the  fovrtli  division  treats  of  the  surgery  of  the  spine  and  spinal  cord,  including 
deformities,  fractures,  gunshot  injuries,  tumors,  etc. 

The  list  of  subjects  is  so  full  that  it  includes  even  tlie  great  surgical  rarities,  and  the 
descriptions  are  sufficiently  complete  to  save  the  reader  from  the  necessity  of  consulting  other 
works  to  obtain  the  knowledge  necessary  to  understand  and  to  treat. 


D.  APPLETON  AND  COMPANY,  NEW  YORK. 


THE  DISEASES  OF 

mnmj  and  childhood. 

I^or  the  Use  of  Students  and  Practitioners  of  Medicine. 

By  L.  EMMETT  HOLT,  A.  M.,  M.  D., 

Professor  of  Dkeases  of  Children  in   the  New   Yorlc  Polyclinic  ;   Attending  Physician  to 

the  Babies'  Hospital  and  to  the  Nursery  and    Child's  Hospital,  New   Yorlc; 

Consulting  Physician  to  the  New  Yorlc  Infant  Asylum,  and  to  the 

Hospital  for  Ruptured  and  Crippled. 

With  7  full-page  Colored  Plates  and  203  Illustrations.     Cloth,  $6.00  , 
sheep,  $7.00  ;  half  morocco,  $7.50. 

SOLID    OlSTLY    BY    SXJBSCRIFTIOJnT. 


American  Medico-Surgical  Bulletin: 

"  This  work  is  in  every  sense  of  the  word  a  new  book  ;  for,  while  the  best  work  of  other 
authors  in  this  and  other  countries  has  been  drawn  upon,  especially  that  in  the  form  of 
monoj^raphs  and  in  the  flies  of  psediatric  literature,  the  majority  is  derived  from  the  author's 
own  clinical  observations.  Obsolete  dicta  handed  down  from  text-book  to  text-book  are 
here  conspicuously  absent,  and  nothing  has  been  accepted  which  has  not  been  carefully 
tested.  ...  It  is  not  venturing  too  much,  after  a  careful  perusal  of  these  pages,  to  predict 
for  this  volume  a  pre-eminent  and  lasting  position  among  the  treatises  upon  this  subject. 
We  heartily  recommend  that  it  find  a  place  not  only  in  the  library  of  every  physician,  but 
wide  open  at  the  elbow  of  every  man  who  desires  to  deal  iutelligently  with  the  problems 
which  confront  him  in  the  treatment  of  infants  and  children  intrusted  to  his  care." 

Nashville  Journal  of  Medicine  : 

"  This  magnificent  work  is  one  of  the  most  valuable  recent  contributions  to  medical  liter- 
ature. It  will  rapidly  win  its  way  to  a  front  rank  with  other  standard  works  upon  kindred 
subjects.     It  is  as  neai'ly  complete  as  a  treatise  upon  tliis  subject  can  be." 

Virginia  Medical  S e mi- Monthly : 

"  When  one  recalls  the  teachinars  of  a  decade  or  two  ago  and  compares  the  inculcationa 
of  to-day,  he  can  scarcely  help  recognizing  that  '  old  things  have  passed  away,  and  all 
things  have  become  new.'  The  volume  before  us  is  practically  the  record  of  information 
obtained  by  the  author  from  eleven  years  of  special  study  and  practice,  so  that  nearly  every 
subject  is  presented  from  the  standpoint  of  personal  observation  and  experience.  The 
information  given  is  therefore  reliable,  for  Dr.  Holt  Ls  a  close  observer  and  a  careful  student 
of  his  ripe  experience.  ...  In  short,  this  book  appears  to  us  to  be  the  best  all-round,  up-to- 
date  book  for  practitioners  and  students  of  children's  diseases  that  we  know  of." 

Medical  Progress : 

"  The  work  before  us  is  one  which  reflects  great  credit  upon  the  distinguished  author. 
Dr.  Holt  has  long  been  known  as  a  most  industrious  and  painstaking  investigator,  and  in 
this  volume  he  sustains  tfiat  reputation.  The  work,  we  may  say  in  a  sentence,  is  fully  up 
to  the  ref|iiir(;mentH  of  tlie  times,  and  there  is  no  advance  known  to  paediatrics  which  has 
not  been  fully  dealt  with  according  to  its  merits." 


D.    APPLETON   AND   COMPANY,    NEW   YORK. 


THE  DISEASES  OF  THE 
STOMACH. 

.  By    Dr.    C.    A.    EWALD, 

EXTRAORDINARY   PROFESSOR    OF    MEDICINE    AT    THE    UNIVERSITY    OF    BERLIN. 

Second  American  Edition,  translated  and  edited,  with  numerous  Additions, 
from  the  Tldrd  German  Edition, 

By  MORRIS    MANGES,   A.  M.,   M.  D., 

ASSISTANT    VISITING    PHYSICIAN    TO    MOUNT    SINAI    HOSPITAL  ;     LECTURER   ON 
GENERAL    MEDICINE,    NEW    YORK     POLYCLINIC,    ETC. 

This  work  has  been  thoroughly  revised,  rearranged,   largely   rewritten,  and 
brought  up  to  date  from  the  most  recent  literature  on  the  subject. 


8vo,  602  pages.     Sold  by  subscription.     Cloth,  $5.00;  sheep,  $6.00. 


"In  giving  the  medical  profession  this  second  revised  translation  of  Prof. 
Ewald's  treatise  on  the  Diseases  of  the  Stomach,  Dr.  Manges  has  placed  the  profes- 
sion under  even  greater  obligations  than  we  owed  for  the  first.  The  first  transla- 
tion was  then  an  almost  exhaustive  treatise,  and  now,  with  so  much  new  and 
valuable  data  added,  the  work  is  a  sine  qua  nan." — Atlanta  Medical  and  Surgical 
Journal. 

"  This  work  as  it  now  stands  is  the  best  on  the  subject  of  stomach  diseases  in 
the  English  language.  No  physician's  library  is  complete  without  it.  It  is  in 
every  way  well  adapted  to  the  requirements  of  the  general  practitioner,  although 
complete  enough  to  meet  also  the  requirements  of  the  specialist." — American 
Medico- Surgical  Bulletin. 

"  The  present  American  edition  is  a  peculiarly  valuable  one,  as  the  editor.. 
Dr.  Manges,  has  done  his  work  in  a  thoroughly  creditable  manner.  His  numer- 
ous notes,  additions,  and  new  illustrations  have  made  the  book  a  classic  one. 
Under  these  circumstances  it  should  find  a  place  in  the  library  oE  every  Amer- 
ican physician,  as  their  clientele  is  composed  of  such  a  large  proportion  of  patients 
suffering  from  gastric  complaints  and  more  or  less  improper  medication  which 
most  often  ends  in  failure.  There  is  no  doubt  that  more  properly  directed  efforts 
in  the  proper  direction,  as  outlined  in  Ewald's  book,  would  soon  remove  from 
Americans  the  reputation  of  being  a  nation  of  dyspeptics." — St.  Louis  Medical 
and  Surgical  Journal. 

"  Dr.  Ewald's  book  has  met  with  a  very  cordial  reception  by  the  medical  pro- 
fession. Within  a  short  period  three  editions  have  appeared,  and  translations 
published  in  England,  Spain,  Prance,  Italy,  and  the  United  States.  To  the 
present  edition  the  author  has  not  only  added  considerable  new  matter,  but  he 
has  also  entirely  rewritten  the  work.  The  arrangement  of  the  chapters  has  been 
somewhat  changed,  and  many  new  personal  observations  and  therapeutic  experi- 
ences added.  The  desirability  of  surgical  interference  is  carefully  considered,  and 
the  pros  and  cons  given  so  far  as  would  be  necessary  to  enable  a  physician  to 
determine  whether  the  aid  of  the  surgeon  might  be  required.  The  translator  has 
done  his  work  well,  and  has  incorporated  much  new  matter  into  the  text  and 
footnotes." — North  American  Journal  of  Homoeopathy. 


D.  APPLETON  AND  COMPANY,  NEW  YOPvK. 


DATE  DUE 


OtMCO  38-296 


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RG  101  R252  1901  C.I 

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